Correction of aesthetic and anatomic deformities of the neck due to aging is a complex proposition, and the planning and approach depends on the findings during your initial examination. More than any area of the body, an in-depth knowledge of the anatomy is mandatory. The surgery can be very simple or highly technical, depending of your findings and surgical proposition. Surgeons should have in their armamentarium all the available surgical techniques to provide the best aesthetic result. Deep cervicoplasty is not for the occasional facial rejuvenative surgeon. You require experience in diagnosing neck problems, executing the proper surgical maneuvers, and effectively tackling acute and late complications if they occur.
Key points
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Aging of the neck is dependent of: skin elasticity, amount of superficial and deep neck fat accumulation, quality and volume of mandibular support, degenerative changes of the cervical spine and body mass index.
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Evaluation of the neck should take into account the superficial and deep structures as it relates the factors above mentioned.
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The surgical plan to be outlined will depend of the aesthetic and anatomical findings.
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Cervicoplasty should not be limited to the treatment of the skin, subcutaneous fat and platysma muscle only. It should consider the changes in the deep structures of the neck: deep cervical fat, digastrics and salivary gland.
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Assessment of volume and quality of support of the entire mandible should be a routine part of your preoperative evaluation.
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Appropriate surgical maneuvers should be planned based on a comprehensive, multidimensional evaluation.
Editor Commentary: Oscar and I began our friendship in the mid 90’s when he was pioneering the endoscopic approach to upper, middle, and lower third facial rejuvenation. His interest in evaluating the anatomical findings in the aging neck and correlating the anatomy to the surgical technique is a common thread throughout his chapter. His advice is logical and intended to safely guide the reader to the best approach to reverse the signs of the aging neck adding ancillary techniques such as suture suspension to improve the outcome .
Overview
Neck aging is still a challenging problem despite that many procedures and techniques have been described over the years. A result that looks good in the early postoperative period can be followed a few weeks or months later with frustrating subcutaneous indurations, skin flaccidity, contour irregularities due to preexisting salivary gland ptosis, digastric “malposition” hypertrophy or subplatysma fat that has not been addressed during the initial surgery. Despite the emphasis of many surgeons on the platysma banding, recurrence of this problem is limited to patients with thin necks.
Not all necks are alike. Aesthetic problems of the cervical area are influenced by the following:
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Age
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Inherent skin elasticity
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Subcutaneous and subplatysma fat accumulation
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Volume and quality of the skeletal support of the mandible from the chin to the gonial angle
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Natural height of the cervical spine
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Presence of arthritic changes on the cervical spine that modifies its height and curvature
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Body mass index (BMI)
Aging of the neck is greatly influenced by the acquired or inherent anatomic, aesthetic, and metabolic milieu. An aging neck in the preexisting presence of low BMI with a long slender neck with a normal curvature and excellent mandibular support is going to be completely different from the aging neck in a patient with high BMI, short neck, and poor skeletal support. Between these 2 extremes are a wide variety of conditions that need to be individualized to treat the patient adequately.
In the first situation (low BMI, long slender neck, normal curvature, mandibular support), simpler techniques, such as a cervicofacial lift from the lateral approach, will work well. In the second situation (high BMI, short neck, poor skeletal support), this simple procedure as is proposed by many surgeons will give at best a mediocre result and, at worst, it will make more apparent the underlying anatomic issues with associated aesthetic deformities.
This simple analysis will explain why you cannot compare techniques when you apply them to different anatomic and clinical situations. Any 2 techniques have to be compared when you apply them to similar clinical situations.
Obesity
Obesity is an ever-increasing problem in the United States and in most of the industrialized world with 60 million obese adults in the United States. Likewise, there is increasing rate of obesity in children and teenagers. Since 1980, overweight rates have doubled among children and tripled among adolescents (Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2006). That is the population that plastic surgeons will be seeing as patients when they approach middle and old age, not to mention the current middle-age and aging population. Obesity affects not only the trunk but also to a significant degree the face and neck. Those patients develop accumulation of subcutaneous fat not only on the anterior neck but also on the posterior neck. They also develop fat accumulation deep to the platysma muscle more than average-weight people. Overweight and obese patients also present more jowling. Obesity is a condition essential to consider during preoperative planning.
Bulging Digastric Muscle
Bulging of the anterior belly of digastric muscle is another problem not routinely approached during cervicoplasty. This bulging can be due to hypertrophy or malposition of the muscle. I do not know why hypertrophy occurs. Malposition of the anterior belly of the digastric is related to the low-lying position of the hyoid bone. This is seen in patients with obtuse- firm necks and in patients with microgenia.
Salivary Gland Ptosis
Salivary gland ptosis is another complex problem that affects many patients and makes it difficult to obtain a nice contour on the neck during cervicoplasty. Salivary gland ptosis can happen in patients with thin or heavy necks. Preoperatively it is easier to spot this problem in thin necks. Patients with heavy necks can camouflage minor or large degrees of salivary gland ptosis. This can be a trap for the inexperienced surgeon because, if you overlook diagnosing this condition, postoperatively you will have an unsatisfied patient who will claim that you missed removal of “a lump” of fat tissue, which obviously it is not. Postoperative explanations to an angry patient do not go well and correction of this problem is more complicated at this stage.
Cervical Spine Degeneration
A problem not recognized in the etiology of aesthetic problems of the neck during aging is the gradual shortening of the cervical spine due to arthritic changes and the natural shrinkage or herniations of the intervertebral discs. Those changes are common to the entire length of the spinal column and the cervical spine is not spared of these degenerative processes. This will shorten the entire cervical cylinder, which, in turn, will push the deep neck and floor of the mouth structures to the areas of least resistance, which are the submandibular and submental triangles. As a consequence, the salivary glands, digastric/mylohyoid muscles and the subplatysma fat will “herniate” anteriorly and inferiorly. The more superficial neck envelope, skin, and platysma muscle will also become more redundant in the vertical and horizontal dimensions.
Mandible Skeletal Support
The size of the skeletal support of the mandible also influences how one ages on the lower face and neck. Poor support at the chin, mandibular body, and angle will allow drift of lower face structures into the neck, blunting the submandibular trough and making more obtuse the cervicomental angle. They will also make more apparent the bulging of the submental/submandibular structures.
Preoperative planning
A careful and comprehensive analysis is important for a good surgical planning. The patient should be made aware of all the issues outlined in the overview: amount of superficial and deep cervical fat, quality of the skeletal support around the chin and mandible, how thick or thin is the entire cervical cylinder, what structures are bulging, if there is salivary gland ptosis or not, how much of skin redundancy exists, the presence or absence of platysma bands, and so forth. Based on these findings, a surgical proposal will be made.
You will need to outline the need to augment the skeletal support, and you will discuss how to treat the deep neck structures and how you will approach the neck. Will you use the lateral approach only or will you also need to use the anterior approach? How will you treat the platysma and skin? These are important considerations because the best cervicoplasty will not give a good result in the absence of good skeletal support. If the patient has heavy, deep structures, a standard cervicoplasty will still have the outcome of a heavy neck postoperatively. Because the management of the salivary gland ptosis is the most complicated and time-consuming proposition, patients need to understand very well the pros and cons of that approach. Many times patients make surgical decisions based on economical factors. He or she has to understand that postoperatively there will be some residuals and sometimes more apparent issues, such as bulging of the salivary gland that he or she did not notice preoperatively ( Figs. 1 and 2 ).
When you add more complicated procedures to the standard cervicofacial lift, these will increase the operative time and cost. This is particularly true if you add chin and gonial angle augmentation and a deep cervicoplasty. On many occasions, the components of the planned surgeries may need to be staged to get the best results and avoid prolonged anesthesia time.
Standard preoperative cardiovascular risk evaluation, avoidance of blood thinners, control of hypertension, and so forth is directed in all patients. Arrangements for postoperative care under a health care provider, usually a certified nurse with experience in plastic surgery postoperative care is made, particularly if a deep cervicoplasty is done, because of the potential of postoperative bleeding.
Recovery time and time to return to work depends on the extent of the surgery. This can vary from 1 to 4 weeks.
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