Deep Neck Contouring through the Ages

Abstract

Deep neck contouring can achieve dramatic results in young and old patients. Both genetic predisposition and aging contribute to the malposition of deep neck structures and a poorly contoured neckline. Depending on the patient's anatomy, deep neck contouring should involve a combination of submental liposuction, platysmaplasty, subplatysmal fat lipectomy, resection of the anterior belly of the digastric muscle, and either cautery or resection of the submandibular glands. Resorption of the facial bony skeleton that occurs with aging affects the ultimate postoperative mandibular contour, and postoperative results thus differ in the young versus old patient. In patients in which there is concern for excess skin laxity, a concurrent facelift is necessary to excise excess neck skin. This article includes a discussion on how a combination of aging and genetics influence a patient's neck anatomy, critical preoperative considerations prior to performing deep neck contouring, intraoperative technique, and adjunct procedures that can further improve a patient's neckline.

 

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Keywords

deep neck contouring - aging - platysmaplasty - digastric resection - submandibular gland - submental liposuction - facelift

Patients are increasingly seeking neck contouring to achieve the ideal neckline and improve overall facial aesthetics. A well-contoured neckline gives the impression of attractiveness, youth, vitality, and confidence.[1] Ellenbogen and Karlin defined the hallmarks of a youthful neck as a distinct inferior mandibular border from the mentum to the mandibular angle, a cervicomental angle between 105 and 120 degrees, subhyoid depression defined as a slight depression inferior to the apex of the cervicomental angle, slightly visible thyroid cartilage, and visible anterior borders of the sternocleidomastoid muscles (SCM).[2] Additional characteristics include a superiorly and posteriorly positioned hyoid bone, strong mentum, absence of excess midline neck skin, and overall submental contours without soft tissue irregularities. [Fig. 1] demonstrates a photograph of iconic actress Audrey Helpburn revealing the ideal female neckline. In contrast, a poorly defined neckline is characterized by an indistinct mandibular border, weak mentum, excess skin and fat, anteriorly positioned hyoid, and contour irregularities caused by bulging digastric muscles and ptotic or large submandibular glands.

Fig. 1 Photograph of actress Audrey Helpburn showcasing a lateral view of the quintessential ideal female neckline. (Stock public domain image courtesy of https://picryl.com/media/audrey-hepburn-william-holden-actress-0451b3).

There has been an evolution of how surgeons address contouring in the neck. In 1968, Millard described a subcutaneous lipectomy in the submental and submandibular regions, which he sometimes combined with a skin facelift.[3] [4] Bruce Connell initially combined subcutaneous fat removal and full-width platysmal muscle flaps as a sling support system and evolved his approach to include addressing subplatysmal fat, digastric muscles, and submandibular glands.[5] [6] [7] [8] Courtiss's submental liposuction removed excess subcutaneous fat in the neck, and the Feldman corset platysmaplasty enhanced the cervicomental angle and addressed platysmal bands.[9] [10] Tim Marten described contouring deep neck structures through a submental incision, which he termed the “short scar neck lift” as well as platysmal myotomy to address platysma hyperfunction.

Through the evolution of neck contouring methods, it has become increasingly apparent that supraplatysmal contouring is not enough to achieve the ideal neckline in many patients. The senior author implemented submental liposuction in the early years of his practice and became disillusioned with its promised effects because contouring issues are often due to deeper structures than subcutaneous fat. In the patient in which deep neck structures are tucked under the skeletal mandibular border, a liposuction and platysmaplasty may be enough. However, in full necks, failure to address mispositioned subplatysmal fat, digastric muscle, and submandibular glands will yield an unsatisfactory result. This article will also describe the powerful utility of deep neck contouring in the young patient. While malposition of deep neck anatomy structures occurs with aging, genetics can predispose even the young patient to a full neck and obtuse cervicomental angle. The senior author has performed deep neck contouring in patients as young as their late teens and has seen early implementation of this procedure slow the perceived aging of their necklace for subsequent years to come. This article will describe preoperative assessment of a patient's age and anatomy and how that influences selection of surgical methodology as well as the senior author's surgical technique in deep neck contouring.

Preoperative Assessment

Anatomy

The submental space is a triangular shaped region with the base of the triangle at the hyoid body and its apex at the mandibular symphysis. The superior and anterior boundary is the mandible, superficial is the platysma, deep is the mylohyoid, inferior is the hyoid bone, and lateral are the anterior bellies of the digastric muscle. The main components of the neck that may be addressed during deep neck contouring include (1) subcutaneous fat, (2) platysma, (3) subplatysmal fat, (4) digastric muscles, and (5) submandibular glands ([Fig. 2]). As patients age, all of these structures have a tendency to herniate anteriorly and inferiorly.[11] In a majority of patients, cervical fat is actually accumulated in the subplatysmal plane rather than the subcutaneous one.[1] The subplatysmal fat pad is shaped as an inverted T with its crosspiece overlying and attached to the hyoid and a narrower portion extending superiorly in the midline, superficial to the anterior bellies of the digastric. Large or ptotic submandibular glands can cause “golf ball”-like contour irregularities in the submandibular neck. Using the platysma as a sling if often inadequate to support the glands above the level of the inferior mandibular border if they are already mispositioned or too large, and they likely need to be addressed with conservative excision. Aging of the facial skeleton should also be taken into consideration during a patient's preoperative assessment and counseling of postoperative expectations. Studies have shown that the bony facial skeleton undergoes significant changes with aging and thus affect the final surgical result after neckline contouring. The mandibular ramus shortens while the mandibular body skeleton is reduced significantly for both sexes with increasing age.[12] The mandibular angle widens from an average of 119 to 132 degrees when comparing age groups of 20 to 40 versus those above 65 years of age[12] ([Fig. 3]).

Fig. 2 This anatomic diagram depicts the location of the five components that may be addressed during deep neck contouring: (1) subcutaneous fat, (2) platysma, (3) subplatysmal fat, (4) digastric muscles, and (5) submandibular glands. (Original illustrations by Medical Illustrator Alex Pfanzelt.)

Fig. 3 Computed tomography of the facial skeleton of a young versus old female, demonstrating reduction in bony volume of the mandibular bone, shortening of the ramus, and increase in the mandibular angle. Adapted from Shaw et al 2011¹².

During history taking at the initial preoperative consultation, it is imperative to ask what therapies the patient has received for neckline contouring. This can predict the level of scar that will be encountered in the neck. These include noninvasive procedures such as ultrasound skin tightening procedures (i.e., Ultherapy), cryolipolyosis, and deoxycholic acid (i.e., Kybella). A prior history of noninvasive procedures can make the subcutaneous plane more fibrous and dissection more difficult. We counsel patients that if they are considering surgical deep neck contouring within the next 5 years to avoid noninvasive therapies prior to surgery. The surgeon should inquire about prior surgeries, such as facelifts, deep neck contouring, submandibular gland excision, hypoglossal nerve stimulation implants, and neck dissections.

Preoperative photos should include standard facelift views as well as the Connell's view, which is a lateral flexion view. The Connell's view can reveal submental fullness that was not previously obvious on a standard lateral view ([Fig. 4]). A large amount of information regarding a patient's deep neck anatomy can be gathered from direct visualization and palpation. To assess whether submental liposuction is necessary, one should do a “pinch test” of the infralobular neck skin to assess its thickness. If the skin is relatively thin, subcutaneous fat is likely not a large contributor. However, if the skin is difficult to pinch and appears thick, then the patient may benefit from a submental liposuction at the same time as deep neck contouring. Another clue to the requirement of submental liposuction is the patient in whom the cervicomental angle is relatively good but their angle of the mandible is obscured. To distinguish subcutaneous versus subplatysmal fat, one can do a pinch test in the midline. Have the patient sit in a neutral position while the examiner grasps the submental bulge or what previous surgeons have termed the “wattle.” The patient is then asked to swallow. If the submental fat moves, the problematic fat pad is likely to be subplatysmal rather than subcutnaeous.[13] Subplatysmal fat also feels firmer and thicker than subcutaneous fat. If platysmal banding is obvious either at rest or with grimace, subcutaneous fat is unlikely to be a large contributor.

Fig. 4 (A) Preoperative photographs of a patient in a standard lateral view. (B) Photograph of the same patient in the Connell view, in which the patient's neck is placed in flexion.

To evaluate whether digastric muscles and submandibular glands are contributory, one should directly palpate the neck for these structures. On the lateral view, herniating digastric muscles appear as paramedian fullness. The contour of the ptotic or large submandibular gland can also be obvious in the submandibular space. Regardless of a thorough physical exam, it is important to note that deep neck structures encountered intraoperatively can differ from what the surgeon expects during the preoperative assessment. As such, the surgeon should be prepared to address all contributory deep neck structures and counsel the patient about all possibilities during the preoperative clinic visit.

The single most important limiting factor to the final neckline contour is the positioning of the hyoid. The hyoid should be palpated on every patient preoperatively. If the hyoid is positioned anteriorly or inferiorly, the patient should be counseled that while significant improvement can be achieved, there is a limit to the depth of the neckline. At the same time, the requirement for a chin implant should be determined preoperatively. Chin implants are a great surgical tool to use in the microgenic patient. The decision to augment the chin is determined from cephalometric measurements independent from the contour of the neck. However, placement of a chin implant in the patient who appropriately requires one can enhance the appearance of the jaw contour and even add several millimeters to perceived “depth” of the neckline. [Fig. 5] demonstrates a patient example of deep neck contouring in conjunction with chin implant placement.

Fig. 5 (A) Preoperative and (B) postoperative 1-week photographs of a female patient who also underwent deep neck contouring with chin implant.

 

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Patient Age

Deep neck contouring has the power to achieve dramatic aesthetic results even in the young patient. While aging undoubtedly transforms a patient's neckline over time, a patient's neck and jaw contour is often predetermined by genetics. It is common to encounter a young patient with posterior hyoid and who may have a genetic predisposition for mispositioned subplatysmal fat, digastric muscle, and submandibular glands. In the senior author's practice, deep neck contouring has been performed in patients as early as their late teens. [Fig. 6] highlights the preoperative and postoperative photographs of a mother–daughter patient duo of ages 58 and 24 years old, respectively. Despite the daughter's young age, one can already see a very obtuse cervicomental angle and neck contour similarities to her mother. During the younger patient's surgery, excision of the subplatysmal fat pad, anterior belly of the digastric, and bilateral submandibular glands were all required. A positive aesthetic result was achieved in both patients, but due to irreversible changes of the skeletal aging over time, the overall postoperative jaw contour is different in the mother versus the daughter. As alluded to previously, the mandibular angle widens and the bone shortens with aging as bony resorption occurs. [Fig. 7] demonstrates the differences in the mother's and daughter's postoperative mandibular angles.

Fig. 6 A mother–daughter patient duo who underwent deep neck contouring by the senior author. In both patients, platysmaplasty and resection of subplatysmal fat, anterior bellies of the digastric muscle, and submandibular glands were required. (A, B) Preoperative and postoperative photographs of a 58-year old patient. (C, D) Preoperative and postoperative photographs of the above patient's 24-year-old daughter.

Fig. 7 Preoperative and postoperative photographs of the mother (A, B) and daughter (C, D) patients with red markings to demonstrate their intrinsic mandibular angles. One can appreciate that the mother's mandibular angle is more obtuse than that of the daughter's.

A patient's absolute age can also clue the surgeon to their degree of skin laxity and the ability of the skin to contract down after removal of deep neck structures. For young patients with high amounts of collagen and elastin within the neck skin, the neck skin can redrape and heal down onto the newly contoured platysma without fear of postoperative skin sagging or laxity. However, if there is pronounced skin laxity on physical exam prior to surgery, there may be excess neck skin that will not contract appropriately. In the senior author's experience, excess skin laxity is often associated with a patient's age of 40 and above. For these patients, there is a high likelihood that a facelift will be required at the same time as deep neck contouring to excise excess neck skin. [Fig. 8] demonstrates a patient case example in which patient with excess skin laxity received a deep neck contouring surgery without a facelift, and the postoperative result reveals skin excess at the mandibular border and in the submentum. The age of 40 is not an absolute rule as one can encounter older patients with good skin turgor and “snap test” who do not require a facelift. Conversely, there are select young patients with surprisingly significant skin laxity who will require a facelift at the same time.

Fig. 8 A patient case example of isolated deep neck contouring in the case of excess skin laxity. (A) Preoperative photograph and (B) postoperative photograph demonstrating excess skin laxity at the mandibular border and submentum. A concurrent facelift to resect excess skin would have improved postoperative results.

 

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Surgical Technique

The following section describes the senior author's intraoperative technique to deep neck contouring. Anesthesia for the surgery is performed with deep sedation. An oropharyngeal airway (OPA) is placed, and two separate tubes are inserted through the OPA opening for blow-by administration of oxygen and for end-tidal carbon dioxide measurement. The senior author has found that general anesthesia and intubation is not required for this surgery, and the postoperative side effects of nausea and vomiting are reduced with deep sedation versus general anesthesia. The local anesthetic is administered as a mixture of 1% lidocaine with 1:100,000 epinephrine, 0.25% bupivacaine with 1:200,000 epinephrine, and tranexamic acid. About 20 mL of local anesthetic is administered in the subcutaneous plane along the intended submental incision and throughout the neck. If submental liposuction is going to be performed, additional local anesthetic is applied to the posterior ear lobule.

A 2-cm incision is made within the submental crease at the midline. Some surgeons have described placing the incision 1.5 cm posterior to the submental crease,[6] [13] [14] but the senior author has found that camouflaging the incision within the crease yields optimal postoperative cosmesis. In the preoperative holding area, it is essential to mark the patient while they are sitting up and meticulously mark the patient's true midline. The central incisors are a helpful landmark to marking the midline. The decision to begin with submental liposuction depends on whether the patient has excess subcutaneous fat. If incorporating liposuction, a stab incision is made into the posterior aspect of the ear lobule. A 3-mm Byron liposuction cannula is attached to a syringe and inserted either through the lobular stab incision or through the submentum and passed through the subcutaneous layer of the neck to create liposuction tracks. Suction is then held in the syringe while liposuction is performed. It is critical to perform liposuction in the subcutaneous plane only, as any deeper plane can destroy the integrity of the platysmal muscle flap that will be critical to achieving the ideal cervicomental angle.

A double-pronged hook is used to retract the incision and short curved scissors are used to dissect in the subcutaneous plane along body the of mandible. If the patient is noted to have tethering of the mandibular ligament during their preoperative assessment, it is important to release the mandibular ligaments bilaterally, which are true osteocutaneous ligaments connecting the mandibular bone to the skin. The subcutaneous plane is dissected with facelift scissors from the incision inferiorly down to the level of the cricoid and from SCM to SCM laterally. It is helpful to use a lighted retractor during this step with the addition of a headlamp for adequate visualization.

Attention is then directed toward entering the subplatysmal plane. For most patients, the platysma is dehiscent in the midline. In select young patients, the platysma can be quite robust and extend to near approximation in the midline. A conservative strip of the midline fascia is resected with scissors from the level of the incision to just inferior to the hyoid bone. The subplatysmal dissection is now performed with either scissors or monopolar cautery to expose the anterior belly of the digastric muscles and inferiorly past the level of the hyoid. To determine the amount of deep neck structures to resect, a line tangent to the inferior border of the body of the mandible is imagined. All deep neck structures that have herniated inferior to that plane should be resected. One must imagine that after surgery, a ruler can be laid flush across the submentum without excess herniation of soft tissue ([Fig. 9]).

Fig. 9 The goal of deep neck contouring is to be able to lay a ruler flat across the submentum after surgery. Using surgery, a line tangent to the inferior border of the body of the mandible is imagined, and all deep neck structures inferior to that plane should be resected.

The subplatysmal fat pad is a T-shaped fat structure with the base of the triangle at the hyoid and the apex extending to the mandible. The subplatysmal fat should be carefully dissected off the anterior bellies of the digastric muscle in a superior to inferior fashion ([Fig. 10A]). It is helpful to dissect the muscle with monopolar cautery with the tip of the cautery instrument bent at 45 degrees. This step should be performed slowly as it is common for veins to be traveling within the subplatysmal fat layer. A large vein is occasionally encountered crossing horizontally in the prehyoid region and needs to be addressed with cautery. If the anterior belly of the digastric muscle needs to be addressed, the superficial layer of the muscle is removed with cautery ([Fig. 10B]). In the senior author's practice, typically a range of 25 to 80% of the volume of the anterior belly of the digastric muscle is removed when the muscle needs to be addressed.

Fig. 10 Surgical technique of deep neck contouring. (A) The T-shaped subplatysmal fat is carefully dissected off the anterior bellies of the digastric muscle in a superior to inferior fashion with monopolar cautery. (B) If the anterior belly of the digastric muscle needs to be addressed, the contributory portion of the muscle is removed with cautery. (C) If the submandibular glands are too large to be treated with cautery, a conservative resection may be necessary. A 3–0 retention vicryl suture is passed through the inferior portion of the gland, and the superficial portion of the gland can then be resected with bipolar cautery. (D) A hyoid suspension suture is performed by passing a 3–0 vicryl suture through the center of the hyoid and the medial edges of the platysma. (E) A traditional platysmaplasty is then performed at the conclusion of the deep neck contouring procedure. (Original illustrations by: Medical Illustrator Alex Pfanzelt.)

Attention is finally turned to the submandibular glands. If they are well tucked under the skeletal confines of the mandible, they do not need to resected. If the glands are ptotic or enlarged below the plane tangent to the body of the mandible, they will require either partial cauterization or resection. The inferomedial aspect of the fascia overlying the submandibular gland is incised, and the fascia is carefully dissected away to protect the marginal mandibular nerve. The gland is then conservatively cauterized with bipolar cautery. If the glands are too large to be treated with cautery, a conservative resection may be necessary. A 3–0 vicryl suture is passed through the inferior portion of the gland in a figure of eight fashion to serve as a retraction suture, and the gland is retracted superiorly toward the submental incision for better visualization. A portion of the gland can then be resected with bipolar cautery ([Fig. 10C]). [Fig. 11] demonstrates subplatysmal fat, the anterior belly of the digastric, and submandibular gland during a deep neck contouring surgery. While it can be tempting to continue contouring deep neck structures, it is important to leave behind interdigastric fat as well as the mylohyoid muscle or else the patient can heal with a “cobra neck” deformity with central submental invagination.

Fig. 11 Anatomical structures encountered during deep neck contouring: (A) submandibular gland, (B) subplatysmal fat, (C) anterior belly of the digastric.

A hyoid suspension and an anterior platysmaplasty are then performed. A 3–0 vicryl suture is used to grab the center of the hyoid bone as well as the medial edges of the platysma on each side at the level of the hyoid ([Fig. 10D]). The knot is buried deep to the platysma when the suture is tied. This cinches the platysma posteriorly to the hyoid bone and creates a sharp cervicomental angle. When suturing the platysma to the hyoid bone, care is taken to incorporate some lateral preplatysmal fat over the area between the hyoid bone and thyroid cartilage. This will prevent the enhancement of the contour of the thyroid cartilage or “Adam's apple” particularly in the female patient. The platysma can be closed in either an interrupted or running fashion with 3–0 vicryl sutures up to the level of the incision ([Fig. 10E]). Subcutaneous fat can be further contoured with facelift scissors if there are any palpable or visible contour irregularities once the skin is redraped over the platysma. The skin is closed with deep dermal 4–0 vicryl sutures and 5–0 nylon vertical mattress interrupted sutures for the skin. It is important to obtain good eversion of the skin for optimal cosmesis. The senior author does not place a drain and has not found it to be necessary so long as meticulous hemostasis is performed with bipolar cautery prior to closure.

Postoperative Care

A facelift dressing is applied with cotton fluff and a kerlix roll. On postoperative day 1, the dressing is removed and an ACE bandage is applied around the patient's head and neck. The bandage is applied lightly and serves the purpose of light support rather than as a tight pressure dressing. The patient wears the ACE bandage for 5 days and then transitions to nightly wear for an additional 7 days. The submental incision is cleaned with hydrogen peroxide and dressed with antibiotic ointment twice a day until sutures are removed on postoperative day 4. In the months to follow, patients may require injections of Kenalog-10 into the submentum to soften firmness in the area. When submandibular glands are either cauterized or partially resected, they can become firm in the postoperative healing period. If so, they can be also injected with Botox or Kenalog-5.

 

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Additional Considerations

In the patient for whom skin laxity was not pronounced enough to warrant a full facelift but in whom the surgeon has concerns about a mild amount of excess skin, one can perform a hemostatic net suture to ensure that the skin heals down onto the platysma. Auersvald described the hemostatic net as an efficient surgical method of preventing hematomas in rhytidectomy.[15] This is performed at the end of the case with a running locking 3–0 chromic gut suture and placed transcutaneously in the submentum to tack the skin down to the platysma. These sutures should be removed on postoperative day 5. As mentioned in the preoperative assessment section, the need for a chin implant should be determined during a patient's preoperative consultation. The senior author uses either a Mittelman Pre-Jowl chin implant with projection, a Flowers Mandibular Glove chin implant, or an anatomical chin implant (Implantech, USA).[16] The implant is placed through the submental incision in a supraperiosteal plane in the midline with the implant phalanges placed in a subperiosteal plane laterally. As the facial bony skeleton resorbs with aging, some patients can have a pronounced pre-jowl sulcus. In this case, it can be beneficial to add fat injections to the pre-jowl sulcus at the same time as a deep neck contour to correct this hollowness. Fat extracted from submental liposuction can be processed for use as a fat injection, or fat can be harvested separately from the abdomen or flank. Deep neck contouring can also be a powerful adjunct to rhinoplasty surgery to improve a patient's overall lateral profile view. When simultaneously addressing a patient's nasofrontal, nasolabial, and cervicomental angles, the lateral profile becomes synergistically pleasing to the observer's eye. [Fig. 12] demonstrates preoperative and postoperative photos of a patient who received a rhinoplasty with deep neck contouring.

Fig. 12 (A) Preoperative and (B) postoperative photographs of a patient in which a rhinoplasty is performed at the same time as a deep neck contour, leading to improvement of the patient's overall lateral view.

Though postoperative complications are rare, patients should be appropriately counseled about risks prior to surgery. There is the risk of bleeding during deep neck contour which, if severe, can be challenging to control through a small submental incision. As such, it is important to dissect the subplatysmal fat layer meticulously and carefully cauterize vessels as they are encountered. Submandibular gland resection should be conservative to avoid excessive bleeding. The facial artery is located superolaterally and deep within the gland and is generally not encountered with a conservative cautery or excision of the gland. If a more distal branch of the facial artery is encountered during submandibular gland dissection, it should be controlled with bipolar cautery. If it is difficult to visualize the site of bleeding, the senior author recommends packing the neck with kerlix gauze and waiting for a few minutes for improved hemostasis and visualization. At times, it can be necessary to ligate the vessel with a suture or vascular clip. The literature reports a 4.5% risk of a submandibular sialocele in deep neck contouring cases in which submandibular gland reduction is required versus when the gland is not reduced.[17] The senior author's incidence of sialocele in cases when the submandibular gland was cauterized or excised is between 2 and 3%. All cases of sialocele have resolved with conservative measurements such as pressure dressings, needle aspiration, and botulinum toxin administration to the submandibular gland. There is the risk of temporary marginal mandibular nerve paresis after deep neck contouring. The senior author has not encountered an incident of permanent marginal mandibular nerve damage. In some cases of marginal mandibular nerve paresis, between 2 and 4 units of Botox can be administered in the contralateral depressor angulis oris muscle to achieve improved smile symmetry. This type of temporary paresis tends to resolve within 6 to 8 weeks after onset. Lastly, while patients may endorse a temporary sensation of submental tightness, the senior author has seen no cases of true dysphagia or altered hyolaryngeal elevation, even with digastric muscle resection. There have been no reported cases of dry mouth.

 

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Conclusion

An ideally contoured jawline can convey increased confidence, vitality, and youthfulness. Deep neck contouring can offer dramatic outcomes in both young and old patients alike. Both genetics and absolute age contribute to malposition of deep neck structures. Preoperative assessment and counseling are important to accurate surgical planning. Deep neck contouring technique depends on a patient's anatomy and may require a combination of submental liposuction, platysmaplasty, subplatysmal fat removal, resection of the anterior belly of the digastric muscle, and conservative resection of the submandibular glands. We have found an association of age greater than 40 years old with excess skin laxity. In patients with excess skin, a concurrent facelift is necessary in addition to deep neck contouring to excise excess neck skin. Deep neck contouring has replaced chin implant and subcutaneous liposuction as the typical adjuncts to rhinoplasty in the senior author's practice. In the appropriate patient, the addition of a chin implant or fat injections can further enhance postoperative results of a deep neck contouring procedure.

 

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Conflict of Interest

None declared.

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18. März 2024