SMAS suspension/platysmal plication

The anterior platysma is approached through a transverse submental incision (Fig. 22.1). The submental skin and a smooth, consistent layer of adjoining fat are then undermined inferiorly to the level of the cricoid. To correct the platysmal bands, the muscle is freed on the edges from the deeper subplatysmal fat and anterior bellies of the digastric muscles. The platysmal edges are grasped with forceps and brought together in the midline. The excess tissue is then resected as described below, and the edges brought together with interrupted and then a running suture from inferior to superior.

Fig. 22.1 Coronal view demonstrating key periglandular anatomic relationships and structures. Note the submandibular ptosis associated with the aging neck. Redrawn from Aesthetic Surgery Journal, Patrick K. Sullivan, M. Brandon Freeman and Scott Schmidt. Contouring the aging neck with submandibular gland suspension July–August 2006. With permission from Elsevier.

Release of the platysma is performed low in the neck. The muscle is then redraped, providing a deeper, more aesthetically pleasing cervicomental angle. If released or incised too caudally, the platysma can “window-shade” over the submandibular glands, or may be denervated and cause lower lip dysfunction.

Subplatysmal fat contouring

Subplatysmal fat may add significant cervicomental angle convexity. The degree of subplatysmal fat is typically an inherited feature, but is also a reflection of total body fat in certain patients. In a subset of patients, the midline subplatysmal fat is the most prominent visible feature of aging in the cervicofacial area. These patients may benefit from a subplatysmal fat contouring through conservative resection and platysmaplasty alone, requiring only a submental incision. We have found this particularly beneficial in some of our young patients. Although the submental incision provides good exposure medially, the additional aspects of the aging neck in most older patients require lateral approaches as well. Any suction lipectomy of the preplatysmal fat must be done conservatively as over-resection is very easy to do and extremely difficult to repair.

A short scar technique is frequently used if skin elasticity is good as we find the exposure frequently allows us all the access we need.

We usually wait to perform preplatysmal fat excision after the final muscle position is set, as we want to prevent the advancement of fat-excised areas above the mandibular border and onto the face. If this occurs, contour deformities may be apparent on the face.

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