CHAPTER 10 Suture-Suspension Neck Lift Technique: A Versatile Technique for Male Neck Rejuvenation
Summary
Performing facial rejuvenation on this male population, especially neck lifts, has gained in popularity and has been very rewarding. In this chapter, I will discuss the evolution of neck lifts on men with the latest modifications and lessons learned over the years.
Introduction
In recent years, there has been an explosion of treatment options to address an aging, ptotic neck. These include all forms of liposuction (laser assisted, ultrasound assisted, Vaser, and so on): Ultherapy, Kybella, CoolMini, and Botox. Many male patients are interested in facial rejuvenation, but unwilling to undergo a full face-lift. Although we have come a long way in terms of destigmatizing plastic surgery for men, there continue to be patients who do not want anyone to know they underwent facial rejuvenation surgery. A neck lift is a procedure that sits well with men more so than a face-lift, in terms of keeping the fact that they had plastic surgery a secret. The suture-suspension neck lift leaves no preauricular scars; it involves only postauricular and submental scars that are hidden, and thus, desirable. While social media, print magazines, and plastic surgery reality TV shows promote a youthful appearance, they do not necessarily educate patients on the different alternatives to achieve a younger, more refreshed look. There is no “one-size-fits-all” procedure that is perfect for every patient. Although it may be important to address facial rhytids and skin laxity to achieve a younger look, addressing jawline contour and creating a more youthful-looking neckline may be enough to achieve the look a patient is hoping to achieve, especially when a man is bothered by his “loose neck” and does not mind facial wrinkles as much.
There are several techniques used to perform neck lifts, both as an isolated procedure and in conjunction with a face-lift. 1 , 2 , 3 , 4 , 5 In 1973, Guerrero- Santos et al. 2 described the muscular lift, followed by Feldman in 1990, 3 who described the corset platysmaplasty. 4 In 1990, Giampapa and Di Bernardo 6 developed the suture-suspension neck lift. Initially, they performed the suture-suspension neck lift on open face-lift patients, but later modified their technique and started performing closed neck lifts. The suture-suspension neck lift has undergone many technical changes and improvements since then. Conrad et al 5 described the Gore-Tex suspension cervical fascia rhytidectomy. In 1995, Giampapa and Di Bernardo 6 described a modified technique that involved the use of platysmal resection as well as two interlocking permanent sutures through a subcutaneous tunnel. This tunnel is immediately below the submandibular border running from the midline to the mastoid bony fascia. This creates an artificial ligament, which is believed to be responsible for the positive long-term effects of this procedure. 6 This was combined with liposuction of the neck to achieve the desired result. The postoperative course included dressings for 7 days.
In 2001, the addition of the fibrin sealant to suture-suspension neck lifts, by Giampapa and Bitar, 7 proved to be very valuable in decreasing the rates of hematomas, seromas, ecchymosis, edema, and postoperative discomfort. Articles on the technical points in refinement of the neck lift technique by Giampapa et al. 8 as well as a 13-year follow-up study on suture-suspension neck lifts by Giampapa et al. 9 have served as a continued effort to improve on this versatile technique.
In the last decade, refinements and additions have been proposed by various authors when addressing neck lifts alone or in combination with face-lifts. Familiarizing oneself with the various techniques enables us as plastic surgeons to balance safety and results to give our patients an aesthetically pleasing facial enhancement while minimizing the risks to do so. 10 , 11 , 12 , 13 , 14 In 2009, I added laser-assisted liposuction to my neck lift technique to improve skin tightening and simplify the procedure because of less bleeding. Additionally, I have been performing neck lifts under local anesthesia since 2013, which has greatly reduced the number of complications associated with general anesthesia. In my experience, most male patients prefer this method over the traditional method of performing a neck lift with general anesthesia or anesthesia with intravenous sedation. I have also found that with the popularity of bariatric surgery growing over the past 20 years, more men who have undergone massive weight loss are seeking plastic surgery for body contouring and facial rejuvenation.
Classification of Neck Types
It is essential to thoroughly evaluate the anatomy of each patient’s neck and subsequently select the appropriate treatment. Most necks fall into one of the following neck classifications14:
Classification of Neck Types
Class I deformity
No midface laxity.
Mild platysmal laxity.
Mild submental fat.
Class II deformity (Fig. 10.2)
Mild midface laxity/mild jowling.
Moderate subplatysmal fat.
Class III deformity (Fig. 10.3)
Moderate midface laxity and prominent jowling.
Moderate platysmal laxity.
Moderate submental fat.
Class IV deformity (Fig. 10.4)
Midface laxity and prominent jowling with extensive labial mandibular deformities.
Moderate-to-severe platysmal laxity.
Severe submental fat and subcutaneous laxity in the lower portion of the neck.
Patients with a class I deformity are ideal candidates for the suture-suspension neck lift and demonstrate excellent early and long-term results. Patients in this category may elect to have neck liposuction only, CoolSculpting, or Kybella as opposed to a neck lift. The advantages of these noninvasive procedures may include reduced cost, faster recovery, less invasive surgery, and fewer incisions. The disadvantage is the lack of dramatic and longterm improvement that the suture-suspension neck lift can provide because of skin excision and tightening of the platysma muscles ( Fig. 10.1 ).
Class II patients should opt for a suture-suspension neck lift to address loose skin and neck muscles. This involves plication of the platysma muscles, removal of submental and subplatysmal fat with liposuction, as well as postauricular skin excision. These patients generally exhibit excellent skin contraction and improvement in neck contour. Any procedure that just addresses the fat will fall short of providing an aesthetically pleasing result ( Fig. 10.2 ).
The treatment for class III patients is to perform a suture-suspension neck lift with resection of a portion of the anterior medial bands of the platysma muscles, vigorous liposuction of the submental and subplatysmal fat, as well as direct excision of the subplatysmal fat. Postauricular skin resection is more extensive in class III necks. These patients exhibit a good result and respond well with good skin contraction to the anterior cervical and lateral neck. Correction of jowling is usually not complete with this technique alone, and other ancillary techniques may need to be employed ( Fig. 10.3 ).
The treatment for class IV patients is a face-lift with complete undermining of the cervical mental area with anterior midface skin. Although suture suspension can be used for the neck lift portion of the face-lift, a more extensive procedure should be undertaken for the best results ( Fig. 10.4 ).
Occasionally, a patient who has a class IV neck cannot have a full face-lift for medical, financial, or other personal reasons. In this case, the patient needs to be told explicitly that a neck lift will not yield results similar to those of a face-lift. Additionally, the addition of ancillary procedures to the midface such as fat grafting or implants may improve the result.
The Six Points of Neck Evaluation
Ellenbogen and Karlin 18 referenced five criteria for a youthful-looking neck:
Acute cervicomental angle (between 105 and 120 degrees).
Distinct inferior mandible border.
Subhyoid depression.
A visible thyroid cartilage.
A visible anterior sternocleidomastoid border.
The suture-suspension neck lift technique addresses the first three criteria. In males, a visible thyroid cartilage contour gives a desirable masculine look, while a visible anterior border of the sternocleidomastoid border can be achieved with the right suctioning technique.
A specific numerical protocol was designed to identify all of the important points of the neck anatomy that undergo the most modification with aging. Additionally, these are the points on which the surgical techniques focus, as described below, which are utilized presently when evaluating a prospective patient for neck rejuvenation. Those points are:
Cervicomental angle depth.
Mandibular border definition.
Mandibular angle definition.
Labiomandibular fold prominence (jowling).
Mental prominence.
Neck width.
Steps for Suture-Suspension Platysmaplasty Technique
Preoperative Assessment
It is essential to explain to the male patient what a neck lift can and cannot accomplish. 16 Generally, male patients have a tendency to rush through the initial consultation and overlook the limitations and potential complications of the surgery. Risks, benefits, and what to expect in the postoperative course are discussed at length. Usually, a patient seeks a neck lift, because he wants an improvement in the appearance of his neck but does not want a full facelift. The main indication for a suture- suspension neck lift is a poorly defined cervicomental angle and mandibular border, which is commonly seen as a result of the aging process. This loss of definition is the result of the loss of key hormones that occur with the aging process, which causes loss of skin tone, loss of muscle tone, and reduced muscle fiber density. A poor definition of the submandibular border is evident from a profile view, when looking at a face and seeing the cheek blend into the side of the neck. In short, contour loss is associated with an aging face. To properly evaluate a patient for a neck lift procedure, it is important to evaluate the midface, jawline, and neck. Next, a suitable operative plan is formulated.
Midface Evaluation
Evaluating the midface is very important for a potential neck lift patient. Minimal laxity in midface structures is important to achieve a good neck lift. At the initial consultation, it should be made clear to the patient that a neck lift is not the procedure of choice to improve the jowls or the nasolabial folds. This point cannot be overemphasized, because patients may feel that they will get all the benefits of a face-lift with a neck lift, but with “less surgery.” This is not true, especially if the patient has significant jowling. A neck lift is meant to make a new cervicomental angle and new definition, but it is not a substitute for a face-lift. Additionally, I generally pinch the patient’s cheeks and jowls during the consultation to remind them physically that these areas will not be improved with a neck lift. Alternatively, I discuss other nonsurgical modalities to improve the cheeks, nasolabial folds, and jowls during the consultation as complementary procedures to the neck lift, such as Ultherapy, Silhouette InstaLift, fillers, and lasers.
Jawline Evaluation
One of the goals of a neck lift is to recreate the mandibular contour by repositioning the platysma and tucking it underneath the border of the mandible. With a wider and more prominent jaw, we obtain better results. One of the initial questions in a consultation is, “Does the patient have a full, wide jaw, or is it narrow?” If the patient has a narrow jaw, the results are not going to be as dramatic as in an individual with a wide jaw. Patients with wide jaws do very well with a neck lift. Patients with a narrow face or a fat neck with lack of jaw definition may not have as good a result. These are generalizations, and exceptions are found every so often.
Neck Evaluation
To evaluate the neck with the patient in an interactive manner, we suggest taking a long Q-tip and pressing against the neck line to show how deep the cervicomental angle is, that is, the distance between the anteriormost tip of the mentum and the thyroid cartilage. Doing this in front of a mirror will show the patient the amount of realistic improvement expected from a neck lift. In males with a narrow neck, even the most advanced neck lift may not yield a dramatic improvement if the patient’s expectations are unrealistic. In evaluating the neck, attention needs to be given to the amount of fat, its distribution in the neck, platysmal laxity, and skin laxity. 17 Categorizing the neck in classes I to IV will aid in determining what procedure is offered to the patient.
Neck Lift or Face-Lift
There are patients for whom a neck lift is not appropriate, and a full face-lift is the procedure that will yield the most improvement. The appropriate way to address these patients is to be assertive about the fact that they will need a full face-lift if they would like dramatic improvement. If there are factors that prevent them from having a face-lift, such as health or financial considerations, then they need to understand and acknowledge that their results with a neck lift will be suboptimal.
A patient may question whether he can first have a neck lift followed by a midface lift in the future. The patient can be given the option to have the neck lift done first and the face-lift later, without the need to redo the neck lift portion of the face-lift.
Suture-Suspension Platysmaplasty Indications
The procedure described here may be an additional procedure in the plastic surgeon’s armamentarium for treating the aging neck. An appropriate candidate for this procedure should meet the majority of the following criteria ( Fig. 10.5 ):
Poorly defined cervical mental angle.
Poorly defined submandibular border.
Absence of laxity in the midface structures (as no tightening of the underlying superficial musculoaponeurotic system fibers and facial muscles in the midface is accomplished through this procedure).
Mild-to-moderate amount of jowling and neck fat (those with large amounts of neck and jowl fat will find some soft-tissue irregularities, if this procedure is used alone in lieu of a face-lift).
Unwillingness or inability to undergo a full face-lift.
Patients with a class I or II neck who seem to be ideal candidates for a neck lift may opt for nonsurgical modalities such as Kybella, CoolSculpting, or laser-assisted liposuction instead. For classes III and IV necks, male patients usually choose a neck lift ( Fig. 10.6 , Fig. 10.7 , and Video 10.1 ). Men find this technique to be an excellent option to avoid preauricular incisions with the multiple problems associated with the beard and hair-baring areas, which are repositioned posteriorly onto the tragus when the standard face-lift incision is used. Furthermore, the neck lift portion of this procedure can be performed during primary and secondary face-lifts for treating fatty necks and acute cervicomental angles, which were difficult to correct with previous surgical procedures.
Advantages of the Suture-Suspension Technique for Neck Contouring
Excellent option for male patients who want a nicely contoured neck and jaw without a face-lift.
Quick recovery of 5 to 10 days.
Little chance of nerve damage or soft-tissue loss, since the neck does not have the abundance of motor nerves the face has, and the skin undermining performed is less than in a face-lift.
No preauricular or hair-baring area incisions are involved.
Can be used during both primary and secondary face-lift for the difficult neck in the obtuse cervicomental angle patients.
Good option for treating the prolapsed submandibular gland deformity.
Surgical Technique
Patients should get medical clearance before proceeding with surgery, and specialist clearance when necessary. It is useful to give prospective patients’ contact information of other males who have had the surgery and consented to be used as a reference.
The prospective patient may contact them by phone and ask them questions. Once the patient is ready to proceed with surgery, the immediate preoperative preparation begins. Optimizing a patient for surgery is done differently by individual surgeons. It is beneficial to place the patient on Arnica for 5 days preoperatively and have the patient stop all blood-thinning supplements and medications. Additionally, it is important the patient abstain from smoking for 2 weeks and alcohol for 1 week preoperatively.
Surgical Marking
The patient is marked in the holding area in the supine position ( Fig. 10.8 ). First, a midline is drawn. Next, the mandible contour is marked, and a line 1.5 cm inferior and parallel to the mandible border is also marked to create the subcutaneous tunnel. The submental curvilinear incision and the inferior border of the dissection are then marked. The inferior border depends on the individual’s neck laxity. Finally, the postauricular ellipse of skin to be incised is marked. The extent of that ellipse, similar to the lower border of dissection, depends on the skin laxity in the lateral neck.
Surgical Preparations
The suture-suspension neck lift can be performed under general or local anesthesia. The preparation of the patient will differ slightly depending on whether or not the patient will be awake. If the patient opts to undergo general anesthesia, they are given prophylactic antibiotics, deep venous thrombosis prophylaxis, and then intubated. The table is turned 180°, and the patient’s arms are tucked to the side. The submandibular area, postauricular area, and lower neck are infiltrated in a fashion similar to a face-lift with about 75 to 150 mL on each side with tumescent solution for a total of 150 to 300 mL (250 mL of saline, 50 mL of 1% plain lidocaine, and two ampules of 1:1,000 epinephrine). The patient is then prepped in the usual sterile fashion and draped with a head and a full body drape, while the tumescent fluid is allowed to take effect. Male patients may need to be injected with more tumescent solution than women because of the increase in blood supply to the neck hair follicles and thicker muscle.
If the patient opts for local anesthesia, the patient is given the following medications in the preoperative area, respectively: 4 mg Zofran, 1 mg Ativan, 500 mg Keflex, and 5/325 mg Percocet. These medications may be substituted if a patient has allergies that prevent him/her from taking one of the original medications. The medications are given 15 minutes apart, and vital signs are taken before each new medication is administered. The surgeon will inject the submental region and postauricular regions with 1% lidocaine with epinephrine 15 minutes after the pain medication is administered. These will be the incision sites as well as entry points for tumescent solution and liposuction. Once the lidocaine takes effect, the tumescent solution will be injected in a similar fashion as described above. Next, the patient is transferred to the operating room where they are prepped and draped in sterile fashion. The patient is reminded not to contaminate the sterile field while they are being prepped. Their arms are tucked to their sides during the procedure.
Laser-Assisted Liposuction
One modification I made to the suture- suspension neck lift is the use of laser-assisted liposuction. In men, the neck area has a richer blood supply than in women because of the blood-rich, hair-bearing bearded area. The advantages of using the laser include skin tightening and less bleeding, especially for a class III or IV neck. After the tumescent solution has taken effect, laser-assisted liposuction is performed ( Fig. 10.9a). I use a Sciton Joule laser with ProLipo PLUS, and the settings are a blend of 1,064 nm 50% and 1,319 nm 50% at 20 to 24 watts ( Fig. 10.9b). Other lasers can be used depending on the surgeon’s level of comfort with the technology. The key is to be conservative until excellent command of the laser liposuction technology is gained because of fear of skin injury if the laser-assisted liposuction is overly aggressive. The neck is liposuctioned initially with a 3- to 4-mm spatulated cannulas and finally with a 4-mm liposuction spatulated cannula. The area of the submandibular tunnel is suctioned along its dermal surface with the 4-mm cannula facing the dermis. This maneuver helps encourage skin contraction in this area creating a better definition of the jawline. Specific areas such as the anterior border of the sternocleidomastoid muscle, the jowl, and the angle of the mandible are liposuctioned in the appropriate patient. Liposuction should never be overly aggressive, because a certain amount of subdermal fat is desirable to keep the neck looking youthful and not skeletonized. Some necks do not need any liposuction. As a rule of thumb, it is better to liposuction less fat rather than be overly aggressive.
Management of the Platysma Muscle
A midline curvilinear submental incision is made in the horizontal crease, and the skin immediately overlying the platysma muscles is elevated with face-lift scissors ( Fig. 10.10 ). A curvilinear incision seems to heal better than a straight incision after scar contraction. Excess subplatysmal fatty tissue is excised under direct visualization with a lighted retractor. The platysmal border in the midline is sometimes resected, if there is significant laxity, in a triangular fashion, and the platysmal borders are cauterized. Prominent platysmal bands are transected for approximately 2 to 3 cm on each side of the platysmal border or are imbricated at the midline with buried 4–0 Prolene sutures. This technique reapproximates and shortens the width of the platysma muscle, thus decreasing the width of the neck.
Skin Excision
The postauricular skin on each side is identified, and an ellipse of skin is excised that extends from the ear lobule area to the midlevel of the postauricular sulcus ( Fig. 10.11 ). This maneuver eliminates the redundant skin from the neck in an easily hidden incision and allows better access to the underlying mastoid fascia. The amount of skin excised is often an area that causes less experienced surgeons some anxiety. How much skin should be excised? The answer is not much! It is better to err on the side of resecting a lesser amount of skin because the skin will redrape over the underlying muscle. If too much skin is resected, the scar may widen, a subsequent “pixie ear” deformity or skin necrosis may ensue. The skin between the mastoid area and the submental area is then undermined to connect to the previously made tunnel in the anterior neck. If a significant amount of skin needs to be excised, such as in a massive weight loss patient, then the patient should be strongly advised to have a facelift instead. If they opt to only undergo a neck lift, the patient must accept that despite an aggressive neck lift, there will still be some loose skin because this procedure has its limits in terms of skin management. Furthermore, a full neck has too little skin rather than too much because when the cervicomental angle is augmented, and a concavity is subsequently created, more skin is required to fill this deeper angle.
After the interlocking sutures have been placed and before closing the incisions, the fibrin sealant is sprayed under the skin flaps or drains are placed (see the next section on The Interlocking Suture Placement). Next, the postauricular incisions are closed with 3–0 Monocryl sutures for the dermis and 3–0 Chromic for the skin. The submental incision is then closed with 3–0 Monocryl and interrupted 4–0 nylon sutures. Xeroform and ABD dressings, as well as a Kerlix wrap, are placed over the skin, along with a Velcro overhead strap for support.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
