Deep Neck Contouring: Indications and Techniques

Abstract

A deep comprehension of key anatomical issues, along with the targeted application of suitable therapies, is vital for attaining exceptional neck contours. Traditional surgical approaches often focus solely on modifying subcutaneous fat and, occasionally, the platysma muscle, neglecting subplatysmal structures. This narrow focus may yield less-than-ideal results and potentially exacerbate existing issues, leading to additional contour abnormalities that prove challenging to correct. In fact, in most cases, there are additional factors deep to the platysma—such as subplatysmal fat, the anterior bellies of the digastric muscles, perihyoid fascia, and the submandibular glands—that contribute to obtuse neck contours. For these patients, accessing the neck through a submental incision allows for precise management of these deep neck structures as required. Unfamiliarity with deep anatomical structures can deter surgeons from performing subplatysmal procedures due to unwarranted concerns about increased complication risks. However, both published clinical series and our clinical experience indicate favorable long-term outcomes with natural, refined, harmonious neck contours and a minimal rate of complications. This article serves as a comprehensive guide, describing indications, strategies, and providing a step-by-step description of the senior author's techniques for mastering deep neck contouring.

Keywords

neck lifting - neck contouring - cervicoplasty - submandibular gland reduction - digastric muscle reduction

An esthetically appealing, youthful neck is characterized by distinct mandibular edges, an acute cervicomental angle, noticeable subhyoid depression, visible thyroid cartilage, and well-defined boundaries of the sternocleidomastoid muscles, all without any visible scarring.[1] [2] [3] Effective neck cosmesis involves identifying the fundamental anatomical problems and applying appropriate interventions.[2] [3] [4] [5] [6] [7] [8] Fullness in the submental or submandibular region, frequently resulting from imbalances in subplatysmal structures, is a concern for individuals of all ages seeking cervicofacial harmony or a defined jawline.[3] [6] [7] [8] [9] Traditional treatments have often been limited to addressing subcutaneous fat, sometimes in conjunction with platysmal adjustments while neglecting deeper neck structures.[5] [8] [9] [10] However, other elements such as platysmal bands, platysmal laxity, subplatysmal fat, prominent digastric muscles, enlarged or ptotic submandibular and parotid glands often contribute significantly to obtuse neck contours and a diminished jawline ([Figs. 1] [2] [3]). Overzealous removal of subcutaneous fat often yields suboptimal outcomes and can exacerbate preexisting problems, leading to additional contour abnormalities that are difficult to correct.[5] [8] [9] [10]

Fig. 1 Preoperative (A–C) and 6-month postoperative (D–F) images of a 45-year-old woman with an obtuse neck contour who underwent a modified composite plane facelift with extended neck dissection and deep neck contouring via a submental incision. The procedure encompassed partial removal of submandibular glands and the anterior bellies of the digastric muscles, subplatysmal fat reduction, as well as anterior platysmal plication and lateral platysma suspension.

Fig. 2 Preoperative (A) and 6-month postoperative (B) photographs of a 50-year-old woman showing an obtuse cervicomental angle, submandibular fullness due to enlarged/ptotic submandibular glands and prominent anterior digastric muscles. She underwent a modified composite plane facelift complemented by extended neck dissection and deep neck contouring via a submental incision. The procedure entailed the reduction of subplatysmal fat, submandibular glands, and anterior digastric muscles, along with anterior platysmal plication and lateral suspension via mastoid crevasse technique.

Fig. 3 Preoperative (A) and 6-month postoperative (B) images of a 40-year-old woman with an obtuse neck who received a modified composite plane facelift, along with extended neck dissection and submental-incision deep neck contouring. The surgical approach involved reducing subplatysmal fat, anterior digastric muscles, and submandibular glands, as well as performing anterior and lateral platysmal procedures.

Since the structures deep to the platysma can be a significant covert contributor to neck contours, effective neck contouring often necessitates surgical intervention through a submental incision to manipulate these deeper structures for optimal esthetic outcomes.[3] [6] [7] [8] [9] [10] Without such targeted treatments, both the well-trained eye and the patient may easily detect that the management of these issues was omitted.

This article extensively explores the indications and strategies for deep neck contouring and provides a detailed, step-by-step description of the techniques employed by the senior author (O.C.).

Indications and Strategies

Several authors have sought to advance knowledge of cosmetic modifications of subplatysmal structures, highlighting the indications and importance of addressing them for optimal esthetic contours ([Table 1]).[2] [4] [5] [11] [12] [13] [14] Feldman[14] reported that in 93% of neck lifts, a submental incision was essential for platysmaplasty and associated subplatysmal interventions, attributing 73% of volume reduction to subplatysmal content changes. Weinstein and Nahai[6] reported that they employed deep contouring in 56% of their patients undergoing neck lift, of which 44% incorporated subplatysmal fat resection, 26% involved tangential digastric excision, and 16% included partial submandibular gland resection. Auersvald et al[4] reported that 85.3% of their neck lift patients required subplatysmal procedures, with 83.9% of these undergoing subplatysmal lipectomy and 60.9% partial submandibular gland resection. Similarly, O'Daniel[5] reported that 62% of his neck lifts cases underwent deep cervicoplasty, with an average subplatysmal volume reduction of 16.3 cm³, compared with 6 cm³ from supraplatysmal fat. In line with these clinical studies, in their recent cadaveric study, Cakmak et al[10] confirmed the significant contribution of subplatysmal structures to obtuse neck contours and advocated for a surgical approach that addresses these deep structures before proceeding to the subcutaneous layer to achieve exceptional neck contours.

Table 1 Indications for deep neck contouring

Deep neck contouring indications:

1. Obtuse neck contours

2. Obtuse cervicomental angle

3. Short cervicomental distance

4. Diminished jawline definition

5. Mismatch between the anterior neck's subplatysmal contents and the mandibular skeletal structure affecting jawline and neck esthetics

6. Platysmal laxity

7. Strong platysmal bands (whether static, dynamic, or recurrent)

8. Excessive subplatysmal fat

9. Prominent digastric muscles

10. Ptotic or enlarged submandibular gland

11. Enlarged parotid glands

12. Thick perihyoid fascia

13. Displaced hyoid bone

Subplatysmal fat deposits are one of the major contributors to obtuse neck contours. Surgical literature on neck lifting reports subplatysmal fat removal rates ranging from 44 to 96%.[4] [5] [6] [10] [14] Cakmak et al[10] found that 28% of the total tissue weight removed during deep neck contouring procedures consisted of subplatysmal fat. The research further indicated that there is a statistically significant correlation between cervical adiposity and body weight and that the removal of subplatysmal fat is essential for achieving favorable neck contour outcomes, particularly in patients who are overweight or obese.[10] In individuals with a pronounced accumulation of neck fat, subplatysmal fat frequently requires intervention. Approaches that target only the subcutaneous fat are likely to produce less than satisfactory outcomes and lead to abnormalities that are difficult to correct.[2] [5] [6] [9]

Distinguishing between soft adynamic platysma bands and firmer dynamic bands is crucial. Soft bands indicate horizontal platysmal laxity ([Fig. 4]), whereas hard bands signify longitudinal hyperfunction ([Fig. 5]).[15] Platysma bands may originate below the upper midline muscle decussation. Optimal results frequently require midline platysmaplasty techniques, especially when firm bands or platysma laxity are present. Lateral platysma repositioning and suspension to the mastoid periosteum are often essential to improve jawline definition while avoiding blunting of the jawline contour ([Fig. 6]).[2] [5] [6] [9]

Fig. 4 Preoperative (A) and 6-month postoperative (B) photographs of a 50-year-old woman with platysmal laxity and soft bands who underwent a modified composite plane facelift complemented by extended neck dissection and deep neck contouring via a submental incision. The procedure entailed the reduction of subplatysmal fat along with anterior and lateral platysmal modifications.

Fig. 5 Preoperative (A) and 6-month postoperative (B) images showcase a 60-year-old woman with hard platysmal bands who underwent a modified composite plane facelift, augmented with extended neck dissection and deep neck contouring via a submental incision. The surgical steps involved reducing subplatysmal fat, low anterior platysma myotomy and plication, as well as lateral platysma suspension.

Fig. 6 Preoperative (A, C) and 6-month postoperative (B, D) photographs of a 50-year-old woman showing obtuse cervicomental angle, paramedian fullness due to anterior digastric muscles prominence, excess skin, and platysmal laxity. She underwent a modified composite plane facelift complemented by extended neck dissection and deep neck contouring via a submental incision. The procedure entailed the reduction of subplatysmal fat and anterior digastric muscles, along with anterior and lateral platysmal modifications.

Patients may exhibit linear paramedian submental fullness due to prominent anterior digastric muscles, which manifests clearly in a head-flexed position (Connel and Hosn's view)[16] ([Fig. 7]). The rate of partial anterior belly of digastric muscle excision in neck lift series varied between 3 and 70%.[4] [5] [6] [14] When required, up to 90% of the anterior digastric muscle can be excised without compromising function.[10] [16] Despite their minor weight contribution, their impact on submental contour is significant.[2] [3] [4] [5] [6] [9] [10] [16] [17] [18] In O'Daniel's study,[5] caudal segments of anterior digastric muscles were reduced by an average volume of 1.3 cm³.

Fig. 7 Patients may exhibit linear paramedian submental fullness due to prominent anterior digastric muscles, which manifests clearly in a head-flexed position (Connel's view). Preoperative (A, C) and 6-month postoperative (B, D) photographs of a 45-year-old woman who underwent a modified composite plane facelift combined with extended neck dissection and deep neck contouring, which included subplatysmal fat reduction, anterior digastric muscle reduction, and anterior platysmal plication and lateral suspension.

Submandibular glands contribute significantly to neck contour and can cause fullness lateral to the ipsilateral belly of the anterior digastric muscle below the mandible ([Fig. 8]).[2] [5] [6] [9] A cadaveric study indicated that the distribution of neck fat usually comprises: 44.7% supraplatysmal fat, 30.7% subplatysmal fat, and 24.5% attributable to the submandibular gland.[17] The prevalence of partial submandibular gland reduction, as reported in current literature, ranges from 16 to 76%, underscoring its critical role in neck lift surgeries.[4] [5] [6] [14] [18] [19] Various theories for their prominence include glandular descent or hypertrophy due to fatty and fibrous deposits.[9] [10] [20] [21] [22] [23] [24] [25]

Fig. 8 Preoperative (A, C) and 6-month postoperative (B, D) photographs of a 50-year-old woman with obtuse neck contours who underwent a modified composite plane facelift, extended neck dissection, and deep neck contouring through a submental incision. The procedure included reductions of subplatysmal fat, anterior digastric muscles, and submandibular glands, as well as anterior and lateral platysmal maneuvers.

Decision between Isolated Deep Neck Contouring and Combined Approaches with Lateral Neck and/or Facelift

The skin primarily serves as a covering, and mere stretching does not address underlying sagging or hypertrophied structures. Improvement comes from modifying deep neck structures rather than just skin tightening. Volume reduction in the subplatysmal space accentuates the cervicomental angle and expands the neck surface area, allowing the skin to redrape without excision ([Fig. 9]). However, the amount of neck skin that can be redraped in this way is limited.[2] [5] [9]

Fig. 9 Intraoperative images of a male patient before (A) and after (B) isolated deep neck contouring via a submental incision. Reducing volume in the subplatysmal region enhances the cervicomental angle and expands the neck's surface area, permitting the skin to reposition itself naturally without the need for excision. This renders isolated deep neck contouring via a submental incision a suitable option for younger individuals with strong skin elasticity and minimal signs of aging. Men, generally exhibiting superior skin elasticity, are also well suited for this procedure.

The suitability of isolated neck lift techniques depends on both patient preferences and the surgeon's anticipated outcomes. If the patient understands the limitations shown through mirror simulations and the surgeon expects satisfactory results, the isolated procedure becomes a viable option. Deep neck contouring via a submental incision can be performed as an isolated procedure, particularly for younger individuals with good skin elasticity and minimal signs of aging. Men, often having greater skin elasticity, also have an advantage with this procedure ([Fig. 9]).[2] [9] Skin removal from the submental incision is theoretically faulty and will worsen rather than improve the neck's form ([Fig. 10]). For those patients with a significant amount of redundant neck skin but wish to avoid a preauricular incision, an inverted V-shaped postauricular incision can be used to remove excess skin and reposition the platysma in a superolateral vector ([Fig. 11]).[2] [9] However, performing a lateral neck lift without a concurrent facelift may yield an unnatural and unfeminine appearance if aging changes in the cheeks, jowls, and jawline are not addressed simultaneously. To achieve balanced and harmonious rejuvenation that yields esthetically pleasing outcomes, it is generally advisable to integrate neck lifts and submental deep neck contouring with facelifts.[2] [9] [26] This combined approach addresses the cheeks, jowls, and subplatysmal structures, facilitates effective repositioning of the platysma, enables precise removal of excess skin, improves skin redraping, and refines the jawline. The senior author advocates for a modified composite plane facelift in conjunction with extended neck dissection and deep neck contouring via a submental incision ([Fig. 12]).[27] [28]

Fig. 10 Preoperative (A, C) and 6-month postoperative (B, D) photographs of a patient who underwent revision surgery due to previously untreated prominent submandibular glands and inappropriate skin excision through submental incision. Submandibular glands were accentuated by excessive subplatysmal fat removal. She underwent a modified composite plane facelift, extended neck dissection, and deep neck contouring, including anterior digastric muscle reduction, submandibular gland reduction, anterior platysmal plication, and lateral platysmal suspension.

Fig. 11 The photo reveals the inconspicuous postoperative incision scar 6 months after a modified composite plane facelift with extended neck dissection. The red and blue lines represent the incision used for her surgery. The blue line specifically marks the postauricular incision that can be employed for an isolated lateral neck lift.

Fig. 12 To achieve balanced, harmonious rejuvenation with esthetically pleasing outcomes, facelifts, neck lifts, and deep neck contouring are often combined. This comprehensive approach addresses the cheeks, jowls, jawline, platysma, and subplatysmal structures while allowing for precise skin excision and effective skin redraping. Preoperative (A–C) and 6-month postoperative (D–F) images showcase a 50-year-old woman who underwent a modified composite plane facelift, extended neck dissection, and deep neck contouring via a submental incision. The procedure encompassed partial removal of the submandibular glands and the anterior belly of the digastric muscles, subplatysmal fat reduction, anterior platysmal plication, and lateral platysma suspension, as well as buccal fat reduction and facial fat injection.

Surgical Technique

Preparation

The patient is positioned in a supine manner, and the endotracheal tube is secured with sutures above the incisors. Following a scalp-to-chest scrub and the application of eye protection, the area is draped. The neck is then profusely injected subcutaneously with a diluted solution of lidocaine, Marcaine, and epinephrine.

Submental Incision

For optimal neck contouring, a submental incision is crucial, whether performing an isolated neck lift or in conjunction with a facelift. To avoid accentuating a “double chin” or “witch's chin,” the incision is not placed along the submental crease; doing so would also limit adequate visualization of the submental region. Instead, the incision is strategically located 1 to 1.5 cm posterior to the crease, extending linearly with a No. 20 blade for 3.5 cm to ensure adequate surgical exposure and minimize scar visibility ([Fig. 13]).[4] [5] [9]

Fig. 13 The submental incision, indicated by a red dotted line, is situated 1 to 1.5 cm posterior to the submental crease, which is marked by a black line. The ligaments of the submental crease are released through a retrograde subcutaneous dissection, denoted by a blue broken line. This particular incision provides convenient access to the deep structures of the neck and facilitates the blending of fat in the chin and submental neck areas, thereby smoothing the transition between them. A black asterisk identifies the location of the bulge caused by the submandibular gland.

Skin Flap Elevation

An assistant utilizes a 10-mm double-prong skin hook to retract the upper edge of the incision while applying countertraction to the flap being elevated inferiorly. Simultaneously, the surgeon employs a lighted retractor to dissect the lower skin flap under direct vision. Using medium blunt Metzenbaum scissors, subcutaneous fat undermining is initiated, preserving most subdermal fat on the skin flap. The subcutaneous dissection is extended well enough inferiorly until the level of the cricoid cartilage to allow platysma maneuvers without skin tethering and to the level of the sternocleidomastoid muscle laterally.[2] [9] Effective platysmal repositioning, which helps enhance cervicomental angle, increases the surface area for skin coverage and is thereby considered adequate for skin tightening and the eradication of horizontal neck lines while eliminating the need for potentially morbid wide skin dissection beyond the lowest horizontal skin line ([Fig. 14]).[29] Limited skin dissection is advised by the senior author, who has ceased extensive subcutaneous undermining,[27] [28] to prevent compromising skin quality. A retrograde dissection up onto the inferior chin is performed, and the ligament along the submental crease is released. This allows the blend and leveling of the chin and submental fat compartments, obtains a smooth transition, and improves the visualization of the platysma and subplatysmal structures ([Fig. 13]).[4] [9] In patients with significant prejowl sulcus or marionette lines, retrograde subcutaneous dissection is further extended superolaterally for safe release of mandibular cutaneous ligaments.[30]

Fig. 14 Efficient repositioning of the platysma obviates the need for extensive, and potentially hazardous, skin dissection beyond the lowest horizontal skin line. Preoperative (A–C) and 6-month postoperative (D–F) images feature a 50-year-old woman who underwent a modified composite plane facelift with extended neck dissection and deep neck contouring via a submental incision. The procedure included subplatysmal fat reduction, anterior digastric muscle reduction, and both anterior and lateral platysmal maneuvers.

Platysma Division and Elevation

To access the subplatysmal space, the fascia between the medial borders of the platysma is incised with monopolar cautery. The edge of the platysma is pulled with an atraumatic forceps, and subplatysmal dissection is performed laterally by cutting cautery to expose the anterior bellies of the digastric muscles and submandibular glands. The dissection is predominantly avascular, and any encountered vessels are managed carefully by bipolar cautery. Preserving the subplatysmal fat on the neck's deep surface simplifies subsequent removal, as excising fat from the platysma's undersurface can be challenging. To enhance visibility and facilitate manipulation, the platysma flaps are temporarily secured to the skin using traction sutures.[9] [31]

Subplatysmal Fat Reduction

Upon elevating the platysma, the plane for subplatysmal fat removal aligns with the anterior bellies of the digastric muscles, while the neck is maintained in a neutral or slightly flexed position. This procedure continues until the anterior digastric muscles and the surrounding deep fascia of the hyoid become visible. Excess fat can also be reduced around the hyoid, under the medial platysma, extending to the capsules of the submandibular salivary glands, and above the thyroid cartilage. Due to the risk of minor vessel disruption, long-shielded bipolar cautery forceps and suction are utilized. Given the lateral positioning of the facial nerve branches below the retracted platysma and the deep location of the laryngeal nerves, this central lipectomy is deemed safe. The location and volume of fat removal are dictated by the desired contour and hyoid angle, taking into account surrounding subplatysmal structures.[2] [9] Untreated but pronounced submandibular glands and digastric muscles warrant minimal fat excision to avoid accentuation ([Fig. 10]). Caution is advised to avoid excessive removal, particularly of interdigastric fat, to minimize risks such as a “dug-out” neck contour or cobra deformity, especially without concomitant digastric muscle volume reduction.[2] [3] [4] [6] [9] [26]

Perihyoid fascia, comprising fibrofatty tissue, establishes a robust connection across the hyoid bone. If thick, it may contribute to an obtuse cervicomental angle. Partial excision of this fascia can significantly improve angle blunting.[2] [3] [4] [6] [9] [26]

Submandibular Gland Reduction

After the removal of subplatysmal fat, the anterior digastric muscle bellies are exposed. If the superficial lobe of the submandibular gland is not visible, a needle-tip cautery is used to make a vertical incision lateral to the lower third of the anterior digastric muscle near its intersection with the hyoid. Gentle upward spreading with blunt-tipped long scissors reveals the gland's lobulated appearance. Extending this incision to the level of the hyoid ensures broad exposure and facilitates easier manipulation.[2] [25] [31] Long atraumatic forceps aid in separating the gland from its capsule using blunt scissors. Extensive mobilization of the gland within its capsule through blunt dissection is essential for managing or preventing intraglandular bleeding. Given the absence of penetrating vessels, the inferior and medial aspects of the superficial lobe are suitable for enhancing intracapsular release.[10] [31] When trimming the gland, only portions extending below the tangent plane of the ipsilateral anterior belly of the digastric muscle and mandibular border are excised. Complete gland removal could risk contour irregularities and xerostomia; therefore, a gradual reduction is advised to maintain both functionality and esthetic neck contour.

An in-depth understanding of the submandibular gland's vascular anatomy is critical for effective intraoperative bleeding management. Awareness of arterial pathways supplying the gland is vital for safe reduction. Cakmak et al.'s cadaveric study indicated that the main blood supply originates from perforating vessels of the facial artery at the posterosuperior region in all cases. Furthermore, in 80% of cases, it is also supplied by the submental arteries in the anterosuperior region.[10] Initial bipolar cauterization of the gland in these regions before cutting helps minimize interactions with major blood vessels while reducing the prominent gland section ([Fig. 15]). High-energy monopolar electrocautery poses a risk of transmitting current and/or heat to adjacent tissue, potentially causing transient marginal or cervical motor nerve injury. In contrast, using bipolar cauterization along the predetermined cut line achieves effective hemostasis while reducing the energy required. A significant portion of the gland is then cut using unipolar cautery along the designated line ([Figs. 16] and [17]). For improved visibility, blunt dissection is used to further open the capsule, and smaller sections are carefully removed for safety.[10] In rare instances of uncontrollable bleeding, the submandibular fossa should be packed with gauze, applying firm pressure to press the gland against both the mandible and the floor of the mouth. Typically, bleeding ceases after gauze removal. It is imperative to clean the surgical site by irrigating and suctioning the subplatysmal space, followed by identification and cauterization of potential bleeding sources.[2] [5] [9] [31]

Fig. 15 The primary vascular supply predominantly originates from perforating branches of the facial artery in the posterosuperior region and from the submental arteries in the anterosuperior region. The white arrow indicates a branch of the facial artery that supplies the gland at the posterosuperior region.

Fig. 16 The photograph demonstrates the initial bipolar cauterization applied to the gland, targeting the area of vascular supply. Following comprehensive mobilization of the gland within its capsule, bipolar cauterization is selectively applied within designated zones to mitigate the risk of hemorrhage. Subsequently, a significant portion of the protruding gland can be safely excised utilizing unipolar cautery, with minimal risk of bleeding. This approach also reduces the potential for nerve injury resulting from the application of energy or heat aimed at achieving hemostasis during glandular resection.

Fig. 17 The figure depicts the excised submandibular gland specimens following surgical removal.

To eliminate dead space at the submandibular cavity, the platysma, gland's capsule, and mylohyoid muscle are sutured using 4–0 Vicryl. The stitch starts at the external surface of the platysma, passes through the gland capsule, attaches to the mylohyoid muscle, and loops back.[31] The gland capsule is then sealed with a continuous 4–0 Vicryl suture.

Anterior Belly of Digastric Muscle Reduction

After subplatysmal lipectomy and submandibular gland reduction, the prominence of the digastric muscle becomes more evident. Optimal assessment of its size is best achieved with the neck in flexion and the mouth closed. In this position, the prominent muscle segment is tangentially excised longitudinally using monopolar cautery, extending from the mandibular symphysis to the hyoid bone ([Fig. 18]). This usually results in a triangular excision of approximately half of the muscle. Variability in muscle size may necessitate more extensive unilateral removal; some patients may require larger segments to be excised, with more tissues removed closer to the hyoid. The goal after reduction of subplatysmal structures is to achieve a uniformly flat muscle ribbon and a flat submental plane that intersects the neck at approximately a 90-degree angle.[2] [9] [10]

Fig. 18 Longitudinal excision of a prominent segment of the anterior belly of the digastric muscle is executed tangentially using monopolar cautery, spanning from the mandibular symphysis to the hyoid bone. The objective is to achieve a uniformly contoured muscle band and establish a flat submental plane that intersects with the neck at an angle approximating 90 degrees.

Platysmaplasty

Both medial platysmaplasty and medial platysma myotomy techniques are effective for treating or preventing platysma problems; while the former addresses both horizontal laxity and bands ([Fig. 4]), the latter focuses on hard dynamic bands ([Fig. 5]). Using corset platysmaplasty, the platysma edges are sutured from mentum to thyroid cartilage with multiple 3–0 PDS interrupted sutures, placed securely but without excessive tightness, thereby inverting the edges. An additional layer of continuous or interrupted sutures reinforces the main suture line, providing a firm yet comfortable final repair. This technique refines neck contour and tightens the jawline while minimizing risks such as suture line dehiscence and platysma band recurrence.[2] [15] In cases with a significant gap between the platysma muscle edges, medial plication may not be feasible, thus necessitating a lateral approach for platysmal suspension.[6]

For patients with hard dynamic bands, horizontal myotomy is performed in addition to platysmal plication. The senior author has updated his technique to place the myotomy well below the hyoid level, avoiding cervical nerve injury and preventing a masculine appearance due to prominent thyroid cartilage.[6] [32] The extent of platysma transection is adjusted laterally based on presurgical evaluation of the nature and severity of the bands. In patients with significant platysmal bands, additional inferior myotomies can be performed to elongate the muscle. Additional sutures placed between the platysma and the deep structures are not preferred, as they may cause significant discomfort, especially during swallowing in the early postoperative period.

Lateral/Extended Neck Lift

For combined (submental and lateral) strategies, the choice of incision—either postauricular or a full facelift—is tailored to individual needs. In cases requiring neck skin excision, the occipital hair-edge incision is the preferred method. This technique effectively removes excess skin while preserving the natural hairline, making it particularly well suited for individuals with sagging neck skin or pronounced lateral folds. In cases requiring combination with a facelift, the incision starts preauricularly, proceeds at the lobule sulcus, extends superiorly along the postauricular sulcus, and then arcs slightly backward before descending just in front of the occipital hairline. During subcutaneous dissection, fat is preserved on the skin flap ([Fig. 11]).

In facelifts or “extended” neck lifts that involve postauricular incisions, it is vital to safeguard the great auricular nerve, which is responsible for ear sensation. The most superficial portion of the nerve is anatomically constant and lies ∼6.5 cm inferior to the auditory meatus proximally at the posterior aspect of the sternocleidomastoid muscle and 1 cm posterior to the external jugular vein. Dissections involving this area necessitate direct visualization to avoid inadvertent injury and leaving an adipofascial tissue layer on top of the sternocleidomastoid muscle.[7] [33] Particularly, the lobular branch of the nerve, located in the area between two vertical lines from the tragus and the antitragus, should be preserved to prevent sensory deficit around the lobulus.[33]

When integrating a neck lift with a modified composite plane facelift,[26] [27] sub-superficial musculoaponeurotic system (Sub-SMAS) facial dissection ceases anteriorly before reaching the facial notch at the mandible level to prevent injury to the marginal mandibular nerve as it becomes superficial and vulnerable when crossing the facial vessels. Uniquely, the cervical branch traverses the deep fascia shortly after departing from the parotid gland and proceeds anteroinferiorly within fibroareolar connective tissue below the undersurface of the platysma. This anatomical positioning renders the cervical branch susceptible during surgical interventions such as subplatysmal dissection and lateral-approach platysma myotomy.[5] [30] [34] [35] [36] [37] [38] [39] The lower portion of the SMAS entry incision is extended slightly posteriorly and downward along the anterior margin of the sternocleidomastoid muscle, creating a subplatysmal window. Using delicate spreading of blunt-tipped scissors, subplatysmal dissection is extended inferiorly around 4 to 5 cm below the angle of the mandible, closely following the anterior edge of the sternocleidomastoid muscle, sufficient for the release of cervical retaining ligaments. Scissors are carefully used to spread beneath the platysma, ensuring that the cervical branch remains undisturbed, lying below the dissection plane, and preserving all nerve fibers raised to the platysma.[30]

The platysma along the anterior border of the sternocleidomastoid muscle is cut a few centimeters inferiorly with a scissor to allow mobilization of the lateral flap. Since the platysma anterior to cervical retaining ligaments is relatively mobile and devoid of collagenous attachments, further dissection is unnecessary.[27] [28] Then lateral platysma tightening is performed to further enhance cervical contour, improve jawline definition, and suspend the submandibular glands, all while avoiding the blunting of the jawline ([Figs. 1] [2] [3] [4] [5] [6] [7] [8], [10], [12], [14], and [19]). The senior author prefers Talei et al's mastoid crevasse technique, which allows effective platysma repositioning and increases gonial depth.[29] A vertical incision is made in the deep fascia anterior to the mastoid tip and posterior to the lobular branch of the greater auricular nerve using cutting cautery to expose a 1 to 1.5 cm deep window on the mastoid periosteum. The lateral edge of the platysma, just under the gonial angle of the mandible and ∼2 finger breadths wide, is pulled superiorly as high as possible (∼80–90 degrees), inset deep into the mastoid periosteum, and anchored with two 3–0 PDS sutures. For patients having prominent parotid glands, a wedge of parotid tissue is excised to facilitate the setting in of the platysma during suspension while preserving its fascia superficially. The weakening of the platysma with a partial (superficial) myotomy can be added to allow a dual vector suspension around the gonial angle and help the platysma accommodate increased travel.[29] As an important notice, the senior author has shifted his preference from a complete horizontal platysma myotomy inferior to the mandible border,[27] [28] [30] to a superficial (incomplete) myotomy, as this approach better preserves lateral platysmal integrity, thereby translating the suspension directly to the submentum, enhancing mandibular definition, and minimizing the risk of cervical nerve injury.

Fig. 19 The hemostatic net sutures before (A) and immediately following their removal (B) on the second day postoperatively.

Subcutaneous Fat Contouring

In neck procedures that include deep neck contouring or are combined with a facelift, postponing subcutaneous fat removal until all deep neck and facelift maneuvers are complete is advised. This allows for an evaluation of the effect of subcutaneous fat as a final touch. Often, after reducing the volume of deep-layer structures, what initially appeared as excess subcutaneous fat may no longer be deemed so ([Fig. 20]). Performing subcutaneous submental liposuction and/or lipectomy prior to facelifting can inadvertently result in a harsh or irregular mandibular contour when lifting regions of the neck to the face through SMAS and platysma manipulation.[9] [10] If subcutaneous fat removal is needed, a conservative approach preserving at least 3 to 5 mm of subcutaneous fat is essential to prevent skeletonization and camouflage contour abnormalities. Aggressively removing subcutaneous fat could cause the skin to adhere to the platysma, resulting in platysmal bands that may become more noticeable after edema subsides.[5] [9] [10] Judicious excision and continuous evaluation are essential elements of this approach. For accurate fat reduction, using Metzenbaum scissors or a flat-tipped liposuction cannula under direct vision is recommended. The ultimate goal is the delicate refining of the fat to maintain a smooth, balanced, and natural appearance while preserving the structural integrity of the treated area.

Fig. 20 Structures beneath the platysma play a crucial role in determining neck contour and often require surgical alteration through a submental incision to achieve optimal esthetic outcomes. In interventions involving deep neck contouring or facelifts, it is advisable to postpone subcutaneous fat removal until deeper structural modifications are completed. This strategy enables a more accurate final assessment of subcutaneous fat, which may not appear excessive post deep-structure volume reduction. The specimen is shown post deep neck contouring, with no subcutaneous fat removed during the procedure.

Incision Closure

Before closing the incisions, it is imperative to ensure that the wound edge thickness and distribution of subcutaneous fat are symmetrical. The cervical edge often displays reduced thickness and fat due to surgical exposure, while the superior mental edge tends to remain more robust. Any discrepancies can be addressed by judiciously excising fat from the thicker side.[9] A foundational layer of 4–0 Vicryl sutures aids in maintaining even fat distribution and minimizes the risk of uneven scarring. Final alignment is achieved using 6–0 Prolene sutures.

Hemostatic Net

To eliminate any dead space and align the SMAS platysma with the skin, continuous sutures are employed across the dissected area. A 4–0 Prolene suture with a 26-mm needle is used, starting at the lowest medial point of neck dissection. The suture line begins with uniform needle insertion: first perpendicular to the skin, then at a 45-degree angle into the SMAS platysma, re-emerging ∼0.8 to 1 cm distally. Gentle tension is maintained to ensure optimal blood flow, with the suture neither too slack nor overly taut, covering the entire dissected area with parallel suture lines ([Fig. 19]). The procedure is mirrored on the other side.[40]

Postoperative Care

Optimal recovery and outcomes are vital following surgical procedures. Traditional dressings may impede blood flow to healing flaps and make it difficult to detect complications; therefore, dressings are omitted. Hemostatic net sutures are applied just before the patient regains consciousness from anesthesia, followed by the application of mupirocin ointment to the incision lines and net sutures.[40]

After facelifts, neck lifts, and especially deep neck contouring, patients are advised to sleep on a flat bed without pillows to prevent obstruction of lymphatic drainage and facilitate the resolution of swelling. Diet is important for recovery following submandibular gland reduction, with a focus on soft, bland, moist, and easily digestible foods to decrease salivary function during the early postoperative period. Salivary stimulants—salty, spicy, sour, dry foods, and foods that necessitate extensive chewing, as well as alcohol—should be avoided for 10 days. Patients may shower starting the first day postsurgery; hair care products do not impede healing. Daily application of mupirocin ointment is advised until the net and sutures are removed. The hemostatic net remains in place until the second day postoperatively, except for patients who underwent submandibular gland reduction, where it is removed on the third day. For net removal, each knot is carefully snipped, and each net loop is individually extracted ([Fig. 19]). While compressive garments should be avoided to preserve blood circulation, mild compressive bands may be beneficial following submandibular gland reduction after the removal of the net sutures.[9] [40] [41] The incision sutures are removed on the seventh day postoperatively. Recovery typically spans 7 to 10 days, with driving permitted after 10 days or when the patient is comfortable without painkillers. Strenuous activities should be avoided for the first 2 weeks; thereafter, light exercises may resume. More rigorous physical activities can be undertaken after 4 weeks.[9]

Follow-up appointments are scheduled at 1, 3, 6, and 12 months with photographs obtained during each of these sessions. After deep neck contouring, lymphedema is common and is generally expected to resolve. Complete resolution may take up to 6 months. Persistent lymphedema may lead to contour irregularities. Lymphatic massages can offer relief. For persistent swelling or skin contracture, 5-fluorouracil injections may be considered.[2] [9] [19] [42] Management of hypertrophic scars involves injections of a combination of 5-fluorouracil and kenacort.[43] Patients should be informed of these potential issues to set realistic expectations.

Complications

Although the cervical branch of the facial nerve is not commonly the primary focus in surgical considerations, it is susceptible to frequent injuries. Injury to the cervical branch can often result in a condition known as marginal mandibular pseudoparalysis, marked by compromised lower lip mobility and an alteration in the appearance of the full-dentured smile on the affected side. This issue generally resolves itself within 3 to 4 months. It is particularly at risk during procedures such as SMAS entry incisions, subplatysmal neck dissections, aggressive neck liposuction, and horizontal platysma myotomies. For risk mitigation, it is crucial to adopt meticulous techniques during subplatysmal dissection via a lateral approach, specifically opting for blunt dissection and gentle vertical spreading of scissors.[5] [30] [34] [36]

Through a medial approach, the primary culprit is the use of monopolar electrocautery near the cervical or marginal mandibular branches during submandibular gland reduction. Another possible cause is performing a myotomy at the level of the hyoid, especially if extended laterally, which could be quite close to the course of the cervical nerve. Placing the horizontal myotomy in a more inferior location, for example, at the level of the cricoid, would avoid any possible risk to the nerve in this location.[2] [4] [9]

In the context of hematomas, O'Daniel[5] reported a significant hematoma in 0.6% of cases, while Feldman[14] segmented them into categories: those requiring surgical intervention at 2.7% and minor ones requiring needle aspiration at 1.3%. The introduction of the hemostatic net approach has revolutionized hematoma management, especially in conditions that heighten risk such as hypertension or vomiting. This technique closes subcutaneous spaces, thereby reducing blood accumulation. It is also effective in addressing increased skin laxity and is particularly beneficial in isolated deep neck contouring through a submental incision. This approach fosters healing without increasing the incidence of ischemia.[40] [41] Based on our experience, the hemostatic net approach has been invaluable in warding off complications such as hematoma, seroma, and skin irregularities. We have stopped using drains and bandages after encountering a major hematoma that required surgical evacuation. After adapting to the use of a hemostatic net, no new incidences of hematomas, either minor or major, have been experienced.[41]

Seromas were documented by Feldman[14] at an incidence of 0.5%. Seromas or persistent submental swelling and induration may specifically arise due to the interruption of lymphatic vessels during subplatysmal fat excision or saliva leakage after submandibular gland reduction. While small seromas often resolve on their own, they might cause fibrosis and contour irregularities. Larger ones may necessitate repeated needle aspirations for expedited healing. For particularly persistent seromas, a drain insertion or net suture placement might be required.

A comprehensive meta-analysis of 1,200 partial submandibular gland resections across six studies reported minimal complications, including hematoma (0.08%), skin flap-related hematomas (1.4%), sialoceles (1.3%), and transient injury to the marginal motor nerve (4.7%). Notably, no cases of permanent motor nerve damage or xerostomia were documented, counteracting misconceptions about elevated risks in deeper anatomical zones that may cause surgical apprehension.[44] Feldman[2] stated that, based on an anecdotal, verbally reported case of xerostomia after bilateral complete superficial lobe resections for esthetic reasons and his own experience, xerostomia is a very rare outcome following partial resection of the superficial lobes. Despite the absence of reported cases of dry mouth after partial removal of submandibular glands, one of our patients still suffers from this challenging issue 6 months after her surgery. Therefore, comprehensive preoperative evaluations are essential, with special attention given to patients showing signs of preexisting dry mouth conditions, autoimmune diseases, or severe dry eye symptoms, as even minor resections are generally avoided in these cases.[2] [10] [41] [45] Patients undergoing submandibular gland reduction should be informed about the potential risks, which include symptoms of dry mouth, bleeding, sialoma, and salivary fistula, although these complications are rare. Additionally, patients should be made aware that only the protruding portion of the gland is excised, leaving the remainder intact, and that other salivary glands, such as the parotid and minor glands, continue to produce saliva.[2] [9]

Despite evidence supporting esthetic partial submandibular gland resection,[2] [5] [6] [10] [19] [23] 89% of surgeons hesitate to perform it due to limited familiarity with deep neck anatomy, despite a low complications rate.[45] The bleeding risk, which is the most feared complication, can be minimized with a thorough understanding of the gland's vascular anatomy. Initial bipolar cauterization of the vascular supply areas (anterosuperior for the facial and posterosuperior for the submental perforators) beneath the mandible minimizes the bleeding risk.[10] This maneuver also decreases the subsequent amount of energy required through monopolar electrocautery. Therefore, the risk of cervical or marginal nerve injury due to the current and/or heat transmitted to adjacent tissue would also be minimized.[10]

Sialoceles were reported in 0.8% of cases by Feldman,[14] while Auersvald et al[4] and O'Daniel[5] observed incidences of 2.0 and 2.6%, respectively. It remains another significant complication, particularly following the partial removal of submandibular or parotid glands. The presence of cloudy sub-SMAS aspirate, testing negative for pathogens, indicates sialocele, with amylase levels as a diagnostic marker. Treatment options include a bland diet, botulinum toxin injection, drainage system implementation, and pressure bandaging, often supported by the administration of scopolamine patches.[41]

Feldman[14] also reported minor complications such as minor infections and postauricular skin crusting (both at 0.4%), and periauricular dysesthesia 1 year postsurgery (0.2%), while O'Daniel[5] reported an additional 2% needed revision surgeries mainly due to contour discrepancies. Multiple studies have highlighted complications associated with deep neck contouring procedures, but Weinstein and Nahai[6] reported a very favorable outlook; out of 100 consecutive patients, none exhibited subplatysmal hematoma, enduring marginal mandibular nerve damage, xerostomia, or severe postoperative neck appearance alterations.

Conclusion

Key elements for achieving exceptional neck contours with natural outcomes include a thorough understanding of intricate anatomy, access to the neck via a submental incision for precise management of neck structures, reshaping structures deep to the platysma as needed, tightening the platysma muscle, and preserving or conservatively removing subcutaneous fat as a final touch. Although a lack of anatomical familiarity may deter surgeons from embracing deep neck contouring techniques, often due to perceived associated risks, both studies reported in the literature and our clinical experience suggest favorable long-term outcomes with natural, durable results and minimal rates of complications.

Conflict of Interest

None declared.

Ethical Approval

All procedures adhered to institutional ethical guidelines, and informed consent was obtained from all participants.

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Publication History

Accepted Manuscript online:
30 October 2023

Article published online:
28 November 2023