The Clinical Problem ( Fig. 14.1 )
Platysma bands are vertical, cordlike structures in the anterior neck that patients often describe as tendons and think detract from an appealing neck. Along with transverse cervical creases, submental skin, and/or fat excess and ptosis, they are key features of an aging neck. Bands may occur medially (paramedian or anterior) or laterally and start to make their appearance in the latter half of the fourth decade in men and women.
Synopsis
Anatomy
Gray’s Anatomy describes the platysma as a broad sheet arising from the fascia of the upper pectoralis major and deltoid. Having crossed the clavicle, fibers ascend superomedially to insert into the mandible, skin, and subcutaneous tissues of the lower face, often blending with the lower oral and angular muscles. The importance of platysmal manipulation in aesthetic neck surgery was first noted in the 1920s.
Three common decussation patterns have been described ( Figs. 14.1 and 14.2 ). The importance of understanding this lies in the fact that mentohyoid decussation provides a continuous sheet for submental support. The 10% of individuals in whom there is no decussation—that is, separation—therefore have minimal structural support. Bands may be medial and lateral; Rohrich et al. have observed that it is only necks with no decussation that can produce medial vertical bands. This is not the entire story, however, because platysma bands may form not only at the leading edge; many static bands result from anterior folding against the relatively fixed midline. Consider the linea alba in the abdomen—a corollary is the jowl that forms only because the mandibular ligament prevents further anterior translocation of the descending cheek substance. Bands may be narrow (<2 cm) or wide (>2 cm) in their separation, and the latter are frequently associated with more fat excess. The prime function of the platysma facial expression, where it conveys fright, sadness, or horror.
The cause is controversial, with two differing views. First, many believe them to be essentially hypertrophic muscle bands. In fact, most adults have some degree of dynamic banding (i.e., on forced contraction; see Fig. 14.1C ). Bands apparent at rest are referred to as static.
Others believe them to be age-related, due to a combination of superficial musculoaponeurotic system (SMAS) attenuation, ptosis, and redundancy, which stops conformation of the tissues to the cervical concavity, and to the stretching of skin and fat overlying the muscles—the two sides of the triangle becoming the hypotenuse. Traditional management was based on tightening of the skin and SMAS, with a repositioning of the platysma muscle to its more usual posterior location. However, a more recent concept is skin redraping after structural reconstitution of the cervicomental angle by midline apposition. Many years of experience have demonstrated that lateral traction alone, however simple in its attraction, is insufficient. Gonzalez has proposed a different view, noting that the sagging senescent skin and platysma become fibrosed, therefore fixing the bands in a static state. However, 30 years of neck lifting have not convinced me, and the bands are not seen when a person is lying supine. Being a skin muscle—part of the panniculus carnosus—the platysma has the same embryonic origin as adjacent skin, so loss of tone is twofold; that is, seen in both skin and muscle.
Iatrogenic (e.g., postliposuction) risk factors were found to be submental obesity and, perhaps unsurprisingly, platysmal nondecussation. Suction of the fat undoubtedly exposes platysmal pathology previously hidden from view.
Management Options
Nonsurgical Options
Botulinum neurotoxin A has been used in 1500 patients from three practices. A four-stage classification, based on various criteria, including platysmal bands and skin laxity, has shown good outcomes unrelated to anatomic variations but correlated with the degree of muscle flaccidity and hypertrophy. The total dose was relatively high, up to 250 botulinum units (BU), as compared to a more conservative 40 BU in a single practice.
Surgical Options
These include the following:
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Percutaneous (e.g., gigli)—probably work primarily through denervation
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Open (e.g., complete incision of the objectionable bands and raising of full-width platysma flaps that are subsequently sutured together in the midline to produce a deep layer sling support )
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Myotomy, with or without midline approximation
Interestingly, the absence of myotomy is difficult to understand.
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Corset platysmaplasty
This is ideal because the lateral platysma is not particularly strong with respect to holding sutures, and central tightening will assist with the minimization of bowstringing.
The Aesthetic Problem
As any Internet search will rapidly reveal, patients complain bitterly about any degree of cervical banding, especially younger, fourth- and fifth-decade patients. The recent proliferation of external and later internal, tissue-tightening machinery bears testament to the deep-rooted dissatisfaction with the smallest of cervical imperfections.
The surgeon’s assessment follows a standard pattern, which includes the following:
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Expectations—often completely unrealistic, but absolutely critical to outcome success in aesthetic surgery, where happiness is defined as when the perception of reality meets expectations
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Skin quality and tone
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Subcutaneous fat presence and quantity
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Band presence—static or dynamic, number and tone
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Additional factors, including mandibular length, chin projection, submandibular gland prominence, and hyoid bone location
The Aesthetic Problem
As any Internet search will rapidly reveal, patients complain bitterly about any degree of cervical banding, especially younger, fourth- and fifth-decade patients. The recent proliferation of external and later internal, tissue-tightening machinery bears testament to the deep-rooted dissatisfaction with the smallest of cervical imperfections.
The surgeon’s assessment follows a standard pattern, which includes the following:
- •
Expectations—often completely unrealistic, but absolutely critical to outcome success in aesthetic surgery, where happiness is defined as when the perception of reality meets expectations
- •
Skin quality and tone
- •
Subcutaneous fat presence and quantity
- •
Band presence—static or dynamic, number and tone
- •
Additional factors, including mandibular length, chin projection, submandibular gland prominence, and hyoid bone location
Surgical Preparation and Technique
Management and Treatment Options
As noted, the patient’s expectations are fundamental, and the balance between increasingly invasive surgery and results versus possible complications cannot be overstated. Although the face is usually relatively forgiving, the neck has a tendency to punish any technical error visibly, no matter how tiny, and edema, especially in the form of seroma, can lead to subsequent skin retraction and deformity.
The need for myomectomies has been debated, but currently they are probably required, if only for the element of denervation they provide because the tendency of platysma is to undergo bowstringing. When this occurs, division is mandatory.
Treatment and Operative Technique
Fig. 14.3 offers an algorithmic summary of the literature, rather than a rigidly didactic protocol. Through a submental incision—within ( Fig. 14.4 ) for concealment or 5 mm behind the crease—the platysma is identified. A retrosulcal incision gives the optimal exposure with a concomitant face lift and is closer to the submandibular glands if surgery is contemplated on them. There is invariably a troublesome bleeder, branching from the facial vessels, at the lateral incision, so good illumination and retraction ( Fig. 14.5 ) are a great help.
