Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 261–270

Management of isolated neck deformity

Tirbod T. Fattahi, DDS, MD
Facial Aesthetic & Reconstructive Surgery, Division of Maxillofacial Surgery, University of Florida,
Health Science Center, Jacksonville, 653-1 West 8th Street, Jacksonville, FL 32209, USA

One of the common signs of facial aging is the formation of redundant tissue in the
cervicomental region. Generally, the redundant tissue is the result of all or some components of
the aging process of the face and neck, which may include cervicomental (submental)
lipomatosis, platysmal redundancy, cervicofacial rhytidosis, skin laxity and dermatomyocha-
lasia, and jowling (Fig. 1). Patients often present to the clinician with complaints of ‘‘turkey
gobbler’’ neck or loss of definition of jaw line. These patients typically have an obtuse
cervicomental angle (ideally approximately 110() that tends to progress with age (Fig. 2).
Surgical procedures for addressing isolated neck deformities include cervical liposuction (open
versus closed) and cervicoplasty (cervical liposuction and platysmaplasty). Other procedures,
such as facelift and hyoid bone suspension/advancement, have been used to address the
aesthetic needs of the neck; however, these are not commonly attested procedures for isolated
neck deformities, as described later in this article.

Anatomy

The various facial aesthetic units and subunits have been described previously. The portion of
the neck addressed by rejuvenative neck surgery is the central subunit bounded by the inferior
border of the mandible superiorly, the anterior borders of the sternocleidomastoid muscles
posterolaterally, and the thyroid cartilage inferiorly (Fig. 3). Within this space lie the following
structures: skin, superficial fascia (subcutaneous tissue) with the superficial fatty layer, platysma,
and the superficial layer of the deep cervical fascia (investing fascia). Rejuvenative surgery of the
neck involves manipulation of these structures within the central subunit of the neck (Fig. 4).

Patient selection and evaluation

Evaluation of patients for aesthetic neck surgery is similar to any other elective aesthetic
surgery. After a review of the past medical and surgical history, patients’ subjective complaints
should be addressed thoroughly. It is imperative for the treating surgeon to be in complete
accord and understanding with patients regarding their specific complaints.
Any preoperative evaluation must include a clinical examination and photographic docu-
mentation. Assessment of the following structures must be done before any decision making:
1. Cervicomental angle
2. Platysmal appearance—evidence of banding or redundancy in the central portion
3. Submental lipomatosis
4. Position of the hyoid bone
5. Position of the mandible and chin and assessment of the occlusion
6. Presence of jowling and facial dermatomyochalasia
7. Position of the submandibular glands

E-mail address: Tirbod.Fattahi@Jax.Ufl.Edu

1061-3315/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cxom.2004.04.006
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Fig. 1. (A, B) Typical appearance of the patient who presents for aesthetic facial surgery. This patient has facial
dermatomyochalasia, jowling, facial rhytidosis, platysmal redundancy, and submental lipomatosis.

Fig. 2. (A, B) Patient with significant submental lipomatosis and platysmal redundancy. Mild jowling also is present.
 T.T. Fattahi / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 261–270 263

Fig. 3. Sagittal (A) and coronal (B) views of the anterior portion of neck.

Fig. 4. Central portion of neck where rejuvenative aesthetic surgery is performed.

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Several aesthetic observations have been made regarding the ‘‘ideal’’ neck appearance,
including smooth neck skin, lack of submental lipomatosis, presence of defined inferior
mandibular borders, subtle inframandibular concavities anterior to the sternocleidomastoid
muscles, well-defined anterior borders of the sternocleidomastoid muscles, cervicomental angle
approximately 110(, and a small thyroid cartilage. Proper evaluation of the neck must involve
manual palpation of the anterior neck structures in animation and repose, which is best
accomplished with the patient standing and facing forward, with the Frankfurt horizontal plane
parallel to the floor. All photographs should be taken in a similar fashion. One can assess easily
the presence of submental lipomatosis and platysmal redundancy by palpating or ‘‘pinching’’
the central submental portion of the neck with two fingers. Platysmal banding or pleats, which
are believed to be secondary to decussation (conjoining and cross-over of the two platysma
muscles in the midline of the neck), laxity of the anterior borders of the platysma muscles, or
weakening of the aponeurosis between the right and left platysma muscles, can be assessed and
visualized with patients’ teeth closed together and tongue pressed against the hard palate.
Position of the hyoid bone can be palpated manually and verified on a lateral cephalometric
radiograph, if needed. Bimanual palpation of the submandibular glands is essential to determine
gland ptosis. Although not common, this condition is typically seen in older patients with
generalized laxity of the platysma and facial dermatomyochalasia.
Intraoral examination is crucial in the initial assessment for aesthetic surgery of the neck.
Patients with gross malocclusion caused by mandibular hypoplasia or persons with microgenia in
addition to a soft-tissue neck deformity must be selected and advised in favor of skeletal surgery.
Perhaps one of the most important preoperative determinations is whether a patient who
presents for an isolated neck deformity is truly a candidate for isolated rejuvenative neck surgery.
Many patients, especially older ones, may have evidence of facial laxity, facial dermatomyocha-
lasia, jowling, and facial rhytidosis in addition to signs of neck aging. The patient who presents
with complaints of neck appearance actually may benefit from a traditional cervicofacial
rhytidectomy which—if performed properly and in conjunction with a cervicoplasty—addresses
the face and the neck. Performing isolated cervical liposuction or cervicoplasty in these patients
does not establish a balanced or harmonious aesthetic result or long-lasting benefits.

Indications

Isolated aesthetic neck surgery is generally indicated in two types of patient populations: (1)
younger patients who have isolated submental/cervicomental lipomatosis without platysma
muscle pathosis and (2) older patients who have submental/cervicomental lipomatosis and
platysma muscle pathosis (platysmal redundancy/laxity, platysmal banding).
Patients in the first category have no evidence of platysmal banding or redundancy. These
patients are generally in their late teens or early twenties. They might be of any body habitus. As
expected, these patients do not constitute a large pool of patients seeking isolated aesthetic neck
surgery. For patients in this category, we prefer an open submental/cervicomental liposuction,
which may be performed under intravenous sedation or general anesthesia. The open technique
of liposuction allows direct visualization of the subcutaneous fatty layer. Tumescent anesthesia
is generally not necessary with this method. In most cases, these patients do not require a
platysmaplasty because there is no evidence of laxity or banding of the muscle in this younger
age group. If laxity is present, however, then one can proceed with the platysmaplasty through
the same incision because a major advantage of an open liposuction technique is the direct
visualization of the superficial surface of the platysma muscle (Fig. 5).
Patients in the second category make up the majority of patients who may benefit from
isolated rejuvenative neck surgery. These patients are generally in their early thirties and older.
They have submental/cervicomental lipomatosis in addition to true platysmal laxity. The laxity
is usually evident in the central portion of the platysma in the form of ‘‘banding’’ or
‘‘redundancy.’’ We prefer to perform an isolated cervicoplasty, including submental liposuction
and platysmaplasty, to address the aesthetic needs of these patients.
As the aging process proceeds, jowling, rhytidosis, and facial dermatomyochalasia
become more prominent and alter the appearance of the neck. If a patient has the aforementioned
 T.T. Fattahi / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 261–270 265

Fig. 5. Typical younger patient who presents with isolated submental lipomatosis. During the open liposuction, it was
determined that the central portion of the platysma was redundant, and a formal platysmaplasty was performed
simultaneously.

signs and evidence of true neck deformity (submental lipomatosis, platysmal laxity), then
the proper surgical treatment should include adjunctive surgical manipulation, such as a facelift.
Performing an isolated cervicoplasty in such a patient should be viewed as a mere tepid attempt
in improving neck aesthetics unless the patient elects not to have more extensive facelift surgery.

Surgical procedure

Regardless of whether we are performing open cervicomental liposuction or cervicoplasty, we

prefer to mark a patient before arriving in the operating room. Marking should be performed
with the patient sitting or standing. The inferior border of the mandible, thyroid notch, anterior
borders of the sternocleidomastoid muscles, periphery or extent of submental lipomatosis, and
any existing cervicomental groove are marked with ink (Fig. 6). If the area is prepared with
alcohol before markings, the ink does not rub off with most scrub solutions used at the
beginning of the operation. It is imperative not to use the existing cervicomental groove as the
incision; this only deepens the groove further and may lead to a ‘‘witch’s chin deformity’’
postoperatively. We prefer to mark a curvilinear incision just posterior to the cervicomental
groove. We routinely obliterate the cervicomental groove during flap elevation to eliminate the
possibility of creating a deepened groove postoperatively. If a cervicomental groove does not
exist, we mark the incision just posterior to the chin subunit. The length of this incision need not
exceed 25 mm. Perioperative antibiotics are administered.
After general or intravenous sedation has been administered, local anesthesia that consists of
lidocaine with epinephrine (usually 1:100,000) is infiltrated in the subcutaneous tissues in the
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Fig. 6. Typical markings for cervicoplasty with liposuction. Markings include inferior border of mandible, anterior
border of the sternocleidomastoid muscle, inferior extend of the lipomatosis, extent of jowling, and the proposed incision
line.

central portion of the neck. Although tumescent anesthesia has been used for aesthetic facial sur-
gery, we prefer to use general anesthesia and obtain hemostasis with direct injection of local
anesthesia with a vasoconstrictor. Next, the incision is made with a number 15 blade through
skin, superficial fascia (subcutaneous tissue), and superficial fatty layer. At this point, one should
be able to see a fatty layer on the deep surface of the skin flap and superficial to the platysma
muscle. Next, any fibrous septae or subcutaneous attachments that form the cervicomental
groove are sharply dissected with the knife through the subcutaneous fatty layer. With the aid of
facelift scissors, a skin flap is elevated in the superficial fatty layer. This flap should extend from
the inferior border of the mandible, laterally to the anterior borders of the sternocleidomastoid
muscles, and inferiorly just past the thyroid cartilage. It is imperative to maintain a uniform
thickness to this flap (approximately 4–5 mm) while preserving some fatty tissue on the deep
surface of the skin flap.
Next, an appropriate liposuction cannula with a unilateral suction port is used for liposuction
of the superficial fatty layer from the platysma. The suction port of the cannula must face the
deeper tissues (fatty layer superficial to the platysma) at all times and not the skin flap. The
integrity of the skin flap with the appropriate amount of fatty tissue can be preserved.
Liposuction of the skin flap may lead to postoperative soft-tissue deformities. After the proper
amount of liposuction has been performed, the platysmaplasty portion of the operation is
initiated (if necessary) by making a small incision (less than 1 cm) in the superior portion of the
platysma muscle just posterior to the attachment of the muscle to symphysis menti. Blunt
submuscular dissection with facelift scissors is then performed. One must be cognizant of the
anterior jugular veins and perforating branches of the submental artery that travel in this layer.
Subplatysmal dissection need not extend to the same lateral and inferior limits as the skin flap
dissection. This dissection can be performed easily because of the subplatysmal areolar plane,
which allows for a blunt dissection with facelift scissors. Once the muscle flap has been elevated,
the central portion of platysma, including the redundant portion, is excised with facelift scissors
bilaterally from a superior to inferior direction. This is usually approximately 3 to 4 cm in a
mediolateral direction. Because the myectomy is performed inferiorly toward the thyroid
cartilage, the two lateral edges of the muscle resection should converge to a point (Fig. 7).
Once the redundant muscle has been excised, the two new edges of platysma are sutured
together in a continuous locking fashion using a 2-0 or 3-0 PDS suture. It is important to
 T.T. Fattahi / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 261–270 267

Fig. 7. Typical appearance of the platysmal myectomy just before (A) and after (B) completion.

perform the platysmal closure with the mouth closed and teeth in occlusion; this ensures the
most posterior (deep) placement of the muscle flap. Some surgeons have advocated performing a
platysmal plication without myectomy to accomplish a platysmaplasty. This procedure has been
performed in isolated cases of platysmal banding. We believe that even in cases in which pleats
or banding of the platysma is present, excision of the central portion of the aponeurosis or
decussation results in a more harmonious postoperative appearance than simply pulling the
muscle edges together. After platysmaplasty, hemostasis is accomplished with cautery. As has
been suggested by others, we prefer to use a thin spray mist of synthetic fibrin sealant on the
superficial surface of the newly reconstructed platysma muscle followed by 5 minutes of direct
pressure application on the skin flap with a folded towel. Synthetic fibrin sealants aid in
hemostasis and adhesion of the skin flap to the underlying muscle, and they decrease the risk of
hematoma formation (Fig. 8).
The incision is then closed using a two-layered technique. We prefer to use 6-0 nylon for
skin closure. A pressure dressing that consists of foam and an elastic wrap is then applied for
approximately 24 to 48 hours. Drains are never used. Excision of excess skin at the inferior
portion of the incision is routinely performed by some surgeons, although it is probably
unnecessary because skin contraction and shrinkage over the next few weeks obviate the need for
this maneuver. Routine excision of the subplatysmal fat is also unnecessary in most cases.

Complications

If proper adherence to sound surgical principles is followed, few complications can arise from
isolated rejuvenative neck surgery. Risk of hematoma is reduced greatly by using fibrin sealants
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Fig. 8. Application of synthetic fibrin sealant spray on the superficial surface of the platysma before closure.

Fig. 9. Before (A) and after (B) (4 months postoperative) photographs of a patient who underwent a cervicoplasty,
including liposuction and platysmaplasty.
 T.T. Fattahi / Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 261–270 269

Fig. 10. Before (A) and after (B) (4 months postoperative) photographs of a patient who underwent a cervicoplasty,
including liposuction and platysmaplasty.

and a pressure dressing. Placement of drains for cervicoplasty is unnecessary. Excessive

liposuction, especially injudicious liposuction of the skin flap, leads to a ‘‘skeletonized’’ look,
often referred to as ‘‘cobra neck deformity.’’ Minor postoperative asymmetries and soft-tissue
indentations are amenable to massage and liposculpture by ultrasound, as recommended by
some surgeons. The edges of the platysmaplasty in the midline often can be palpated for a few
weeks postoperatively, although this usually resolves with time. It is imperative that patients
refrain from strenuous exercise (and abrupt turning of the neck) postoperatively for
approximately 1 month because it can cause dehiscence of the newly sutured platysma edges.
Sutures are routinely removed on postoperative day 5, and topical medicament is applied to the
incision as needed.
Some surgeons have advocated using a cervical suture sling procedure using various materials,
such as Gore-Tex or nylon sutures, suspended from the mastoid fascia to treat anterior and central
neck deformities. Although this approach may produce a pleasing effect (albeit not consistently),
the sling is often palpable and—even worse—visible with animation of the lower face.
A recently popularized technique involves liposuction of the anterior neck and platysma-
plasty of the muscle edges followed by simultaneous lasering of the subdermal plexus and the
superficial aspect of the platysma. This procedure can compromise the vascularity of the skin
flap greatly and should be used with extreme caution.
Nonsurgical treatment of platysmal bands with Botulinum toxin A has been advocated by
some surgeons. This method of therapy is temporary and inconsistent and often produces
minimal improvement in the appearance of platysmal banding.
A comment must be made regarding addressing isolated neck deformities with a facelift and
hyoid suspension. Facelift procedures should be reserved for individuals who have aging of the
face. Performing a facelift-type of incision simply to pull the neck skin back does not produce
long-lasting benefits because the issues of platysmal redundancy and submental lipomatosis are
not addressed. Performing a hyoid bone elevation, although beneficial to the appearance of the
anterior neck, only addresses the position of the hyoid bone without modifying other
components of neck aging.
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Summary

Rejuvenative surgery for isolated neck deformities can be a fulfilling procedure for patients
and surgeons. With precise understanding of the anatomy of the anterior neck, proper patient
selection, and sound surgical execution, consistent and attractive postoperative outcomes can be
expected in every case (Figs. 9, 10).

Further readings

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Surg 2001;17:117–22.
Brennan HG, Giammanco PF. The ptotic chin syndrome corrected by mentopexy. Ann Plast Surg 1987;18:200–8.
Cardoso de Castro C. The anatomy of the platysma muscle. Plast Reconstr Surg 1980;66:680–3.
Coleman JJ, Jurkiewics MJ, Nahai F, et al. The platysma musculocutaneous flap: experience with 24 cases. Plast
Reconstr Surg 1983;72:315–21.
Evans TW, Stepanyan M. Isolated cervicoplasty. American Journal of Cosmetic Surgery 2002;19:91–113.
Fattahi T, Mohan M, Caldwell G. Clinical applications of fibrin sealants. J Oral Maxillofac Surg, 2004;62:218.
Feldman JJ. Corset platysmaplasty. Plast Reconstr Surg 1990;85:333–43.
Gradinger GP. Anterior cervicoplasty in the male patient. Plast Reconstr Surg 2000;106:1146–54.
Jasin ME. Submentoplasty as an isolated rejuvenative procedure for the neck. Arch Facial Plast Surg 2003;5:180–3.
Kane MAC. Nonsurgical treatment of platysmal bands with injection of botulinum toxin A. Plast Reconstr Surg 1999;
103:656–63.
Kennedy BD. Suction assisted lipectomy of the face and neck. J Oral Maxillofac Surg 1988;46:546–58.
Lee J, Koire B. Evaluation of the platysma interlocking suture sling for rhytidectomy. J Oral Maxillofac Surgery
1998;56:943–9.
Lesavoy MA, Creasman C, Schwartz RJ. A technique for correcting witch’s chin deformity. Plast Reconstr Surg 1996;
97:842–6.
McKinney P. The management of platysma bands. Plast Reconstr Surg 1996;98:999–1006.
Matarasso A, Matarasso SL, Brandt FS, et al. Botulinum A exotoxin for the management of platysma bands. Plast
Reconstr Surg 1999;103:645–52.
Noodleman FR, Harris DR. The laser-assisted neck lift: modifications in technique and postoperative care to improve
results. Dermatol Surg 2002;28:453–8.