Cosmetic Follow-Up Limited Incision Submental Lipectomy and Platysmaplasty

In essence, the article published in 1998 described a technique for performing a platysmaplasty in conjunction with suction lipectomy of the submental area through a 2.5-cm submental incision to treat the “heavy” neck or the neck with an oblique cervicomandibular angle without using periauricular skin incisions.1 I reported my results of 56 patients treated between 1981 and 1997. As this relatively small number of patients over a 16-year period suggests, the technique was applied selectively. The long-term effectiveness of this technique in appropriate candidates has been good, considering its limitations (Figs. 1 and 2). One limitation is the patient who has more than mild jowl formation. The technique is performed best for the patient without jowl formation, as illustrated by the patient in Figure 1. The inability to adequately treat a jowl with this approach is illustrated by the patient in Figure 2. Another limitation of the technique is inelastic neck skin. The technique is not appropriate for the patient with atrophic, sun-damaged skin, which does not contract well over remodeled submental fat and platysma muscle. I continue to use this procedure as it was described in 1998 except for two modifications. The first change in technique was in my method of neck flap dissection and elevation. For the first 56 patients, I used hydrostatic expansion of the submental and anterior neck subcutaneous fat with 200 cc of saline injected after placement of an infiltration block using 0.25% lidocaine. I wanted to leave an adequate layer of fat on the elevated skin flap, and I felt at the time that saline-expanded fat could be more easily dissected to leave a smooth, 5to 6-mm layer of intact fat under the skin flap. However, a 5to 6-mm thickness of salineexpanded fat was not thick enough in some patients. I learned that postoperative neck skin looked smoother and softer if more subcutaneous fat was left under the skin flap, and I found that could be judged best without the hydrostatic expansion of the fat. Although the salineexpanded fat did make dissection easier, its fluid content occasionally misled me into thinking that I was leaving more fat than was actually the case. Although I still remove excess fat from the submental area both above and under the platysma muscle, I now leave at least 7 to 8 mm of unexpanded fat under the skin flap there. Except for obese individuals, I rarely remove any fat at all from under the anterior neck skin, because aggressive fat removal over the anterior neck may give the postoperative patient a skeletonized appearance, especially the patient with marginal skin tone. The second change in technique I made relates to the platysma muscle plication step of the procedure. In the original article, transection of the platysma muscle at the level of the thyroid cartilage was performed routinely, because it allowed the muscle to slide cephalad and create a better defined cervicomandibular angle. However, this muscle transection at the most distant point from the submental skin incision was frequently associated with troublesome bleeding during surgery, and I believe that muscle transection was associated with most of the cases of postoperative hematoma formation I experienced. I now usually omit