Chapter 10 Neck Rejuvenation
Summary
Introduction
Loss of neck contour, especially at the cervicomental and cervicomandibular angles, is a common sign of aging. Procedures to rejuvenate the face and neck are among the most commonly performed cosmetic surgical procedures in the United States. The delineation of the cervicomandibular angle is an important factor in facial harmony and an overall youthful appearance.1,2 Rejuvenation of the aging neck gives a more pleasing appearance to the soft tissues in that area, and can cause the face to appear more youthful as well. The goal is to provide an even, smooth platysmal layer that closely invests the thyroid cartilage, hyoid, and floor of the mouth. Procedures to lift and redefine the jaw line and submental region are often used as adjuncts to rhytidectomy.
Anatomy and effects of aging
Traditionally, facial rejuvenation techniques have involved repositioning of portions of the superficial musculoaponeurotic system (SMAS) and skin. In the neck the SMAS blends with the platysma fascia to form a continuous sheet.3 Here, signs of cervicofacial aging are initially manifest as faint vertical platysmal bands overlying the thyroid cartilage and hyoid. These then progress to longer, more pronounced bands as more support is lost from the retaining ligaments and the platysma descends further.4 The laxity of the platysma causes a cervical obliquity, which is compounded by supra- and subplatysmal fat deposits. Subplatysmal fat can exacerbate the development of cervicomental angle obliquity. Submandibular gland ptosis may contribute to cervical fullness as well, supplying bulk laterally, below the angle of the mandible. The end result of these processes is a neck with a prematurely aged appearance.
Indications
Patients with lesser degrees of submandibular gland fullness may benefit from suspension, whereas those with very significant submandibular gland ptosis or hypertrophy may be candidates for partial resection.6 The idea of aesthetics as an indication for submandibular gland resection, which is a technically challenging operation, is controversial.2,7 The primary criticism for resecting the gland is the risk of nerve injury. Prior to their widespread acceptance, SMAS-rhytidectomy techniques were similarly criticized for their risk to the facial nerve. Through multiple studies documenting the anatomy of the facial nerve and refining the surgical approach to it, SMAS procedures were accepted. Similar studies of the submandibular gland have been undertaken, but controversies remain.4 All of the nerves in the area of the gland, with the exception of the autonomic plexus, are found exterior to its capsule.
