Continuing Medical Education Examination—Facial Aesthetic Surgery the Hammock Platysmaplasty

8/11/2019 Continuing Medical Education ExaminationFacial Aesthetic Surgery the Hammock Platysmaplasty

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C o n t i n u in g M e d i c a l E d u c a t io n E x a m i n a t i o n F a c i a l

A e s t h e t ic S u r g e r y

T h e a m m o c k P l a ty s in a p l a st y

A n t o n i o F u e n t e d e l C a m p o M D

L e a r n i n g O b j e c t i v e s :

T h e r e a d e r i s p r e s u m e d t o h a v e a b r o a d u n d e r s t a n d i n g o f p l a s ti c s u rg i c a l p r o c e d u r e s a n d

concep t s . Af t e r s t udy ing th i s a r ti c l e t he par t i c i pa n t shou ld be ab l e to :

1 . Bet t e r und er s t an d t he m echa n i sm o f ag ing as i t r e l a t es to t he neck .

2 . Con cep tua l i ze a l imi t ed i nc i si on p l a tysma p las ty t echn ique su i t ab l e fo r the ag ing neck

of mi ld to severe degree.

P h y s i c ia n s m a y e a r n 1 h o u r o f C a t e g o r y 1 C M E c r e d it b y s u c c e s s fu l ly c o m p l e t i n g t h e

e x a m i n a t i o n b a s e d o n m a t e r i a l c o v e r e d in t h i s a rt ic l e . T h e e x a m i n a t i o n b e g in s o n p a g e

253 .

In th is ar t ic le , I descr ibe the per t in ent ana tom y o f the neck, the character is tics tha t def ine

a youth fu l-appearing neck, subsequent changes associa ted with the aging neckline, and the

surgica l procedure I am currently us ing for res toring the yo uth f u l appearance o f the neck

th ro u g h a su b m en ta l a p p ro a ch . Th is p ro ced u re co n si s ts o f o ver la p p in g th e p la tysm a m u s -

cles ( in double -breasted fash ion) in the mid line by use o f la tera l tract ion su tures

anchored to the per ios teum and deep fascia o f the contra la tera l masto id reg ion . In cases o f

severe muscular laxi ty , the p la ty sma muscles are part ia l ly sec t ioned horizon ta l ly a t the

level o f the hyoid bone, creating four mu scle f laps (extend ed procedure) . This mu scular

sect ion ing functionally e longates the abnormally shortened media l edge o f the muscles .

The subs eque nt overlapping o f these f laps perm its deepening o f the cervicomental angle .

Th e su rg ica l p ro ced u re i s p er fo rm ed exc lu sively th ro u g h a su b m en ta l a p p ro ach , a n d

avoids the poster io r traction o f the p la tysm a muscle . I ts ind ica tions are descr ibed in deta i l.

Furthermore, the ind ica tions a nd procedures for a supple me nta l cervica l approach in those

patien ts with skin redundancy are d iscussed . My experience with 43 consecutive patien ts is

p resen ted , wi th a fo l lo w- u p o f 2 yea rs a n d 9 m o n th s .

e ag ing p rocess m an i fes t s it se l f i n t he neck i n severa l ways a f f ec t i ng neck vo l -

u m e s t r u c tu r e a n d c o n s i s te n c y . T h e s e c h a n g e s a re p r o b a b l y r e l a t e d t o f a t d e p o -

s i t ion mu scu l ar l ax i ty and poo r sk in t one r espec t ive ly . W i th r egard t o vo lum e

b o t h p r e p l a t y s m a l a n d r e t r o p l a ty s m a l f a t m u s t b e e v a l u a t e d a n d t r e a t e d . R e g a r d i n g

changes i n con tou r and cons i s t ency i t i s a l so necessary t o de t e rm ine whethe r t he p rob -

l em is r e l a t ed t o the muscu l a tu re t o t he sk in o r bo th and each aspec t m us t be t r ea t ed

From the Div is ion of Plastic and

Recons truc t ive Surgery, and the

Plastic Craniom axillofacial Surgery

Research D epar tment o f the

Hospital Dr. Ma nuel G e a

Gonzalez, Univers idad

Nacional

Autonoma de Mex ico , Me x ico C i ty ,

Me x ico and the Cran io facia l

Surgery Cl inic of the Hospital

Infantil de Me xico

Dr .

Fredrico

Gomez , Mex ico C i ty , Mex ico .

Acce pted for publ ication Apr i l 28,

1 9 9 8 .

Repr int requests: An tonio Fuente

de l Campo, MD, Urbana no . 155-9

Col. Independencia, M exic o City ,

Me x i c o , D .F . 5 3 8 3 0 .

Copyrigh t 199 8 by the Amer ican

Society for Aesthetic Plast ic

Surgery, Inc.

1 9 0 - 8 2 0 X / 9 8 / $ 5 . 0 0 + 0

7 0 1 9 1 8 8 9

2 4 6 A E S T H E T I C S U R G E R Y J O U R N A L ~ J U L Y / A U G U S T 1 9 9 8


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igure

1 Subm ental approach for wide subcutaneous dissection and

dissection o f the medial edges of the platysma. The sutures are placed

through the medial edges of the flaps at the level of the hyoid.

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i

igure

2

Use of the custom-designed suture passer and the fixation o f

bridle sutures to the masto id region.

specifically. Cur rent con cepts of be auty dictate tha t the

face should project well-defined volumes, prominences,

and depressions. The su bmand ibular l ine, which dem ar-

cates the separat ion between the face and the neck, runs

from one m astoid to the other, passing below the

man dible at the level of the hyoid . It should be well-

defined, establishing a cervicomental angle of 105 to 120

degrees. 1

The platysma is directed from its inferior origin on the

acromion and infraclavicular region upward an d inward

toward i ts insertion on the inferior mandibular border.

Its medial portion inserts over the medial third of an

obl ique l ine along the external aspect of the mandib ular

body. Its external aspect mixes wit h fibers of the depres-

sor anguli oris, the mentalis, the risorius of Santorini, and

the orbicularis o tis muscle of the lips to term inate in the

skin of the oral com missure. 2 Along the midl ine of the

neck, platysmal f ibers join or interm ix below the men ton

with the corresponding fibers from the contralateral s ide,

forming a ret icular s t ructure. The platysm a muscle main-

tains an int imate relat ionship with the skin through a

network of aponeurot ic reinforcements fi rst described by

Bosse and Papillon 3 and later by Furn as 4 as retainin g

l igaments (platysmoauricular , anterior platysmocuta-

neous, and m andibula r l igaments) . With the passage of

t ime, the platysma becomes detached fro m the deeper

planes. This muscular at tenu at ion and the weight of the

soft t issue displaces the skin, giving it a conv ex, pendu -

lous, and flaccid appearance. The central aspects of the

igure

3 Posterior traction of the bridle sutures to overlap the

platysm a in double-breasted fashion.

paired muscles separate in the midline. Frequently, medi-

al bands appear, pe rhaps ow ing to vertical shortening of

the correspo nding musc ular fibers. Mc Kin ney classifies

these bands in four different grades , from m inimal to

severe. Establ ishing the grade of d eform ity has im portan t

implicat ions for planning the appropriate surgical t reat-

ment .

A variety of procedures have been espoused for neck con-

tour res torat ion. Fat ty excess ma y be corrected with l ipo-

The ammock Platysmaplasty

A E S THE TIC S URGE RY JOURNA L JUL Y A UGUS T 1 9 9 8 2 4 7


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igure 4 Tacking sutures for fixation of the platysma in its newly

overlapped position.

igure 6

Overlapping of the superior platysmal flaps to restore con-

tour in the upper neck.

igure

5 Sectioning o f platysma at the level of the hyoid for treatment

of grade 1H and I V platysmal bands.

suct ion or directed excis ion. Re dund ant skin has been

addressed with ret roauricular and cervical incis ions, and

muscular laxi ty has been corrected by restoring the

platysma to i ts proper anatom ic locat ion.

Platysmaplasty has taken on ma ny forms, including later-

al plication , 6 sectioning and flap rota tion, 7 simple m idline

suturing, 8,9 progressively ten sioned midline sutures, 1

mus cular Z-p lasty, 11 resection of musc ular bridles, '12

and suspension sutures. 13 M ost of these proce dures

require a cervical approach, necessitating wide incisions

even in pat ients in wh om the fundam ental problem is

muscular an d does no t require cu taneous resect ion. In

general , those procedures designed to be perfor med

through a single, submental incision are effective only in

pat ients with minor deformit ies . The progressive corset

plication 1 is an excellent procedure . H owe ver, in my

experience, i t has drawb acks associated with mu scular

bunching in the m idl ine, causing extra volume in this

area, reducing the dis tance between the subme ntal l ine

and the mental symphysis , and l imit ing the possibi l i ty of

achieving a slim neck. Also, with this procedure, some-

t imes I f ind i t di ff icul t to determine the r ight am oun t of

tension to apply to achieve a good result.

After weighing both the advan tages and d isadvantages of

these techniques, I have developed and implemented a

procedure over the past 3 years that uses a combina t ion

of these principles. This hybrid approach results in suc-

cessful res torat ion of neck conto ur, w i th good funct ional ,

muscular recon struct ion solely throu gh a minima l sub-

mental incision.

Surgical rocedure

This procedure is perform ed as ambu latory surgery under

local anesthesia with int ravenous sedat ion or under gen-

eral anesthesia. During the procedure the neck is extend-

ed. I overlap the platysma in a double-bre asted fashion

in the midneck to restore neck contou r, using one of two

248 AES THETI C S URGERY . J OURNAL J ULY/AUGUS T 1998 Volume18 Number4


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igure

7 Bilateral traction of bridle sutures with subsequent tacking

sutures for fixation of the upper and lower platysmal flaps in their new

position.

igure

8. A

Preoperative view of a 56-year-old female patient with

grade IH rhytidosis prominent jowls and platysmal bands. B

Postoperative view at 18 months after endoscopic subperiosteal face lift

blepharoplasty and extended ham mock platysmaplasty ensuring ade-

quate coverage of thyroid cartilages.

variations: direct overlapping for grade I (minimal) and

grade II bands (moderate) , and muscular Z-plasty

(extended proced ure) for grade III (significant) and IV

(severe) deformities.

In those patients in whom liposuction is indicated, I

begin with a 5 mm incision located 1 cm behind the sub-

mental l ine. With a 4 m m can nula, preplastysmal and

retroplastysmal fat are remov ed in both the submental

and the subm andibular regions. I am careful to leave a

homo genous, thin layer of fat at tached to the skin to

avoid the appearance of leathery skin that com mon ly

accom panies aggressive superficial suctioning. Once lipo-

suction is com pleted, the incision is enlarged to 3 cm, and

a thoro ugh subcutaneous dissection is performed, com-

pleting the flap elevation that began with th e blun t dis-

sect ion performe d with the l iposuct ion cannula. In those

patients with jowls, further dissection is undertaken. A

wide subperiosteal dissect ion of the m enton and the infe-

rior mand ibular border is made ei ther through the same

submental incis ion or throu gh a supplemental inferior

vest ibular approach, avoiding damage to the mental

nerve. This maneuver frees the insertions of the chin mus-

culature and indirectly frees the superomedial insertions

of the platysm a. 14,1S Me ticulous hemo stasis is obta ined

ei ther with a long, insulated cautery (C olorado t ip) , or

with a s imilar insulated suct ion-cautery cannula that

offers the advan tage of smoke extract ion.

The locat ion of the subm andibular l ine should begin at

the hyoid, running upward towa rd the ma stoids bi lateral-

ly , and passing beneath the ma ndibular angle. Throug h

the submental incision, the entire medial edges of the

platysma muscles are approac hed, and their middle thi rd

is dissected free from the deeper structures.

In the case of grade I and II bands, the m edial border of

each muscle is drawn towa rd the m idl ine with a 4-0

polyglactin stitch placed throu gh it at the level of the sub-

mandibular line (Figure 1). Through a 1 cm bilateral

retroauricular slit incision, a custom-made, long, blunt,

curved needle is introduced to pass the sutures across the

neck. This needle is passed subcutaneously along the

length of wha t wil l be the new sub mand ibular sulcus . On

one side, the needle is passed through to the midline exit-

ing through the submental incis ion. The ends of the pre-

viously placed platysmal suture from the contralateral

side are passed th rou gh the hole in the tip of the needle;

the needle is then d rawn back throu gh i ts tunnel (Figure

2). On the other s ide, the needle must pass through the

fibers of the ipsi lateral platysma, cont inuing on deep to

the muscle to the midline. At this point, the contralateral

muscular suture is similarly drawn back throu gh the

retroauricular incis ion. The tw o sutures are t ightened,

overlapping the two muscles in the midline (Figure 3).

For the best results, i t is conve nient to prev iously calcu-

late the point of ma xim um desired superimposi t ion

ahead of t ime by use of the calculat ion to es t imate the

level at which the needle transfixes the platysma muscle

on the ipsilateral side.

The ammo ck Platysmaplasty

A E S T H E T I C S U R G E R Y J O U R N A L ~ J U L Y / A U G U S T 1 9 9 8 2 4 9


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igure

9.

Incisions for redundant skin resection of the neck.

A

Cervical and retroauricular skin resection for grade III rhytidosis. B

Additional compensatory skin resection around the lobule.

The two sutures are draw n symm etrical ly upwa rd in a

bridlel ike fashion with mod erate tension and are sutured

to the deep mastoid fascia and periosteum. This maneu-

ver permits relocat ion of the m uscle and enables the sur-

geon to determine the best am oun t of t ract ion and

muscular overlap necessary to obtain a n aesthet ical ly

pleasing neckline. Then, throug h the sam e subm ental

route, the free edge of the platysma, which overlies the

other one, is sutured to the deeper muscle with several 4-

0 polyglactin stitches Figure 4). The intimate overlap-

ping of the two m uscles al lows a perman ent scar to

develop after about 8 days, which prevents loss of con-

tour correct ion once the sutures dissolve. The subm ental

incision is closed with an intraderm al running suture, and

the mastoid incisions are closed with a simple subcuticu-

lar 4-0 po lyglactin stitch.

In grade III and IV platysmal bands, which manifest vis i-

ble muscular shortening, I perform an extende d proce-

dure. The muscles are sect ioned horizontal ly from their

med ial edge at the level of the hyoid Figure 5). This sec-

t ioning produces fou r t r iangular f laps; two are superolat -

eral ly based, and the other two are inferolateral ly based.

These flaps are then fixed at their vertexes and over-

lapped with tension as previously described Figure 6).

This part ial muscular sect ion percept ibly lengthens the

muscles, permit t ing ample overlap of their superior and

inferior portions. This provides exce llent definition, con-

igure

10. A Preoperative view o f a 58-year-old female patient with

grade IV rhytidosis prominent jowls and hanging neck. B Postopera-

tive view at 14 months after endoscopic subperiosteal face lift

blepharoplasty cervical liposuction suhperiosteal dissection of mental

area and extended ham mock pla~ysmaplasty.

Table Complications

Submental cutaneous irregularit ies 7.0

Small hematom as 4.7

Skin rippling 2.3

Partial relapse 2.3

tour a nd support in the submental region and along the

subm andibular area. The tw o inferior f laps are also over-

lapped to remodel the lower neck. As described for type I

and II bands, the procedure is completed by suturing the

free edges of the overlapped m uscles Figure 7). I do no t

typical ly drain the woun ds. They are p rotected after

surgery with an elastic garment that is worn cont inuously

for 1 week a nd intermit tent ly thereafter for 2 weeks.

Results

I have used this procedure on 43 pat ients 35 women ,

and 8 men), ranging in age from 35 to 66 years . Thirty-

two of the pat ients were t reated exclusively throug h a

submental incis ion with out removal o f skin. With a m ax-

imum fol low-up of 2 years and 9 mo nths, I have

observed excel lent long-term maintenanc e of the postop-

erat ive correct ion of neck conto ur. T he best resul ts were

observed in those cases in which the skin retained its

capaci ty to contract wel l Figure 8). Com plicat ions have

been few; only two pat ients had smal l hema tomas th at

were readi ly drained during an office visi t. In three other

250 AESTHETIC SURGERY JOURNAL JULY/AUGUST 1998 Volume18 Number4


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igure

11. A,

Preoperative view of a 47-year-old obese female patient

with grade III rhytidosis, platysmal bands, heavy jowls and marionette

lines. B, Postoperative view at 6 months after mini-invasive subperios-

teal face lift, blepharoplasty, facial and cervical liposuction, subperios-

teal dissection of the mental area, and extended hammo ck platysma-

plasty. Not e the improvement in the marionette lines and jowling.

patients areas of submental cutaneo us adherence devel-

oped, result ing in tempo rar ily visible ir regular i ties. In on e

case, lateral skin rippling occurred, most likely as a result

of insuff ic ient subcutaneous dissection in this region

Table). No other ser ious complications were encoun-

tered. There were no cases of neurovascular compromise

or recurrent deformity.

iscussion

This procedure avoids the poster ior traction of the

pla tysma musc le commo n to many s tandard ce rv icoplas-

ty procedures. I t a l lows excellent pla tysmal suspension

and intimate redrapin g of the muscle , e levating the deep

neck structures, such as the submandib ular glands. The

tension applied to the muscle restores the muscular sup-

port of the neck, imparting adequate suspension without

the r isk of centra l muscular diastasis, which m ay occur

with the posterolateral traction procedures.

The use of a br idle of suture or other foreign mater ia l to

give form to the neck does not change the fundamental

deformity, so that if the suture loosens o r breaks, the cor-

rection is lost. The two bridle sutures that I use to relo-

cate the muscles permit the determ ination o f the correct

amount of la teral traction and muscular overlap to

obtain an aesthetic and natural neck contour . Further-

more, the rest of the sutures placed along the bo rders of

the two overlapped muscles guarantee the permanence of

the muscular r econs t ruc t ion wi thout having to depend on

Figure 12. A,

Preoperative view of a 38-year-old male patient. B,

Postoperative view 8 months after ha mmoc k platysmaplasty.

the br idle sutures fo r long-term results . I use delayed

absorp tion sutures because they need to last only long

enough to a llow the c icatr ic ia l process to fuse the muscles

together . I t is equally effective to use nonab sorbab le

sutures such as nylon, but in m y experience, these mater i-

a ls can be palpable in thin-skinned patients. To avoid

skin irregularities, it is necessary to free the skin from the

underlying muscle , which permits muscle traction with-

out pull ing o n the skin.

The new con tour of the neck wi th a deep submandibula r

arch, which is obtained with this procedure, requires

more skin to cover i t adequately. Thus in mo st cases

there is notab ly less skin redundancy , and in some cases,

the appea rance of f laccidity disappears a ltog ether . In

addition, the natural e lastic i ty of the skin a llows i ts redis-

tr ibution, redraping, and adherence to the muscles, so

that in most cases, skin resection is not necessary.

In general terms, this mus cular co rrection achieves excel-

lent results in the con tou r of the neck, a l though there are

cases in whi ch skin laxity grade III rhytidos is) needs to

be cor rec ted by drawing the sk in upward and pos te r ior ly

throu gh a cervical and re tro auricular incision. In these

cases, when the cutaneous traction causes bunching of

the skin arou nd the lobule , the re troauricular incision is

generous ly extended downw ard and forward to pe rmi t

excess skin resection. I t is impo rtant to ensu re that this

incision does not viola te the l imits between the lobule

and the tragus, to avoid the scar becoming visible Figure

9) . In cases of severe skin redund ancy grade IV rhytido-

sis), which presents with skin redu ndan cy extendin g

across the cheek, i t is necessary to lengthen the incision

The amm ock Platysmaplasty AESTHETIC SURGERY JOURNAL ~ JULY/AUGUST 1998 25 1


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a c r o s s th e p r e a u r i c u l a r r e g i o n . T h e n e e d f o r c u t a n e o u s

r e s e c t i o n d e p e n d s o n t h e a e s t h e t ic c o n c e p t o f t h e s u r -

geon . B ut abov e a l l , i t i s the pa t i en t ' s idea o f a na tu ra l

r e s u l t t h a t s h o u l d g u i d e th e s u r g e o n . M a n y p a t i e n t s

c h o o s e t o a v o i d t h e c e r v i c a l sc a r . A l t h o u g h i n s o m e c a s e s

th i s im pl ie s l eav ing a ce r ta in cu tan eous f l acc id i ty , the

pa t i en t s be l i eve th i s re su l t i s m ore na tura l look ing .

T h e h a m m o c k p l a t y sm a p l a s t y p r o c e d u r e l im i ts t h e n e e d

for ce rv ica l inc i s ions to a m in im u m of cases . I t can be

p e r f o r m e d a s a n i s o l a te d p r o c e d u r e o r a s p a r t o f a f ul l

f a c e li ft . It e v e n p e r m i t s c o n t o u r i m p r o v e m e n t o f t h e n e c k

i n t h o s e p a t i e n ts w i t h p r o m i n e n t t h y r o i d c a r t i la g e s . I n

w o m e n i t is i m p o r t a n t t o e n s u r e a d e q u a t e c o v e r a g e o f th e

t h y r o i d c a r t il a g e , a n d n o t t o a p p l y e x c e s s iv e tr a c t i o n t o

t h e m u s c l e f la p s , t o s o f t e n t h e n e c k ' s c o n t o u r a n d t o

avoid m ascu l in iz ing i t s appea rance (F igure 10) . By f ree -

i n g u p t h e m u s c u l a t u r e o f t h e m e n t o n ( a n d i n d i r e c tl y th e

s u p e r o m e d i a l i n s e r t io n s o f t h e p l a t y s m a ) , c e n t r a l l y o r l a t -

e r a l l y d i r e c t e d t e n s io n a c t s o n t h e l o w e r c h e e k , i m p r o v i n g

b o t h th e j o w l s a n d t h e m a r i o n e t t e li n e s ( F ig u r e s 1 1

and 12) .

P o s t o p e r a t i v e e d e m a is m o d e r a t e , a l l o w i n g t h e p r o m p t

r e s u m p t i o n o f d a i l y a c ti v it i es . T h i s r a p i d r e s o l u t i o n o f

te l l t a le su rg ica l changes wi th m in im a l v i s ib le s ca r r ing

p r o v i d e s a v e r y a t t r a c t iv e p r o c e d u r e , p a r t i c u l a r l y t o m a l e

p a t i e n t s , w h o m a y n o t h a v e l o n g h a i r t o c o v e r s ca r s i n

the pos te r io r ce rv ica l reg ion .

E n d o s c o p i c t e c h n i q u e i s a v e rs a t il e a n d p o w e r f u l t o o l i n

the p la s t i c su rg ica l a rm am enta r ium 16; i t pe rm i t s a be t t e r

v i s u a l iz a t i o n o f t h e s u r g ic a l f i el d th r o u g h a m a g n i f ie d

i m a g e o n t h e m o n i t o r a n d a l l o w s m o r e d i r e c t e d as si s-

t a n ce f r o m t h e s c r u b t e am . T h e h a m m o c k p l a ty s m a p l a s ty

i s equa l ly easy to ca r ry ou t und e r d i rec t v is ion . Thus i t is

a s a c ce s si b le t o t h o s e w h o a r e c o m f o r t a b l e w i t h e n d o -

s c o p ic t e c h n i q u e s a s t o t h o s e w h o p r e f e r a d i r e c t v i e w o f

the surgical f ie ld.

e f e r e n c e s

1. El lenbogen S, Kar lin JV. Visual cr i ter ia for success in restor ing the

you th fu l neck . P las t Recons t r Surg 1980 ;66 :826-37 .

2 . Cardoso de Cas tro C . The ana tomy o f the p la tysma musc le . P las t

R e c o n s t r Sur g 1 9 8 0 ;6 6 :6 8 0 - 3 .

3. Bosse JP, Papi l lon J . Surgical ana tom y of the S MA S at the m alar region.

In: Transactions of the 9t h Interna tional Congress of Plastic and

Recons t ruc t ive Surgery . New York : McGraw-H il l, 1987 :3 48-9 .

4 . Furnas DW. The re ta in ing l igaments o f the cheek . P las t Recons t r Surg

1 9 8 9 ; 8 3 : 1 1 - 6 .

5 . McK inney P. The management o f p la tysma bands . P las t Recons t r Surg

1 9 9 6 ; 9 8 : 9 9 9 - 1 0 0 6 .

6. Guerrero Santos J , Espai l lat G, Morale s F. Mu scula r l i f ts in cerv ical

rhy t idop las ty . P las t Recons t r Surg 1974 ;54 :127-31 .

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2 5 2 A E S T H E T I C S U R G E R Y J O U R N A L ~ J U L Y A U G U S T 1 9 9 8

Volume18 Number4

Continuing Medical Education Examination—Facial Aesthetic Surgery the Hammock Platysmaplasty

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