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This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. Skoogdescribedasubplatysmalapthatelevatedthepla-tysmamuscleoftheneckandlowerpartofthefacewithoutdetachingtheskin.MitzandPeyronieidentiedthesuper-cialmusculoaponeuroticsystem(SMAS)in1976astheanatomicalbasisbehindSkoogstechnique.TheSMASconceptrapidlyemergedas,andcontinuestobe,centraltofaceliftingtechnique.Duringthesametimeperiod,adjunctivetechniquestoaddresstheheavyneckandaugmentneckliftingwerecomingintovogue.In1968,Millardetaldescribedsubmentalandsubmandibularlipectomyviashortsubmentalincisionstoaddressthefattyneckincombinationwithfaceandnecklifting.FurtheradvancementbyConnellin1968describedneckcontouringusinglipectomycombinedwithamuscleslingmadefromfull-widthplatysmamuscleapstoprovidedeepsupport.Techniquestoaddresstheheavyneckex-pandedtoincludesuctionlipectomyoftheneck,introducedbyCourtissin1985.Managementoftheagingneckthroughthevariabledesignofincisions,theapplicationofopenlipectomy,ultrasonic-andlaser-assistedlipectomy,andsuc-tion-assistedlipectomyhavealsobeeninvestigated.Additionalmethodstoimprovetheappearanceoftheplatysmawerereported.Thecorsetplatysmaplastywasdescribedin1990andjoinedamultitudeofpopulartechniquesincludingpartialplatysmamusclesection,Z-plastytechniques,andlateralormedialplicationoftheplatysma.9,17In1997,ConnellandShamoundescribedthesignicanceofdigastricmusclecontouringinnecklift-In2006,subm
andibularglandsuspensiontoimprovetheappearanceoftheneckwasdescribedbySullivanetal.Thisvarietyofmethodsformanagingtheanteriorplatysmabands,aswellastheSMAS,havealsobeenreportedandarewidelyadopted.20,24Thedeepplanetechniquehasbeenadvocatedtoaddresstheheavyneck.Asthesetechniquestoaddressneckcontouringandliftingevolved,severalsystemsemergedforassessmentandclassi-cationofneckappearanceinthe1980s.EllenbogenandKarlindescribedvisualcriteriaforrestoringtheyouthfulneck,whereastheDedosystemgradedsuboptimalneckappearancebasedonpresenceofskinlaxity,submentalfataccumulation,platysmabanding,retrognathia,andhyoidmalposition.37,38Thecurrentliteratureonrhytidectomyisrepletewithtechniquesspanningthespectrumoftraditionallong-scarandshort-scarsurgeries.Amongtherecentinnovationshavebeenthedevelopmentofseveralshort-scartechniques. Fig.1)Clinicalphotographsofpatientwhoexhibitsanatomiccharacteristicsfavorableforshortincisionrhytidectomy,thatis,favorablechinprojection,favorablehyoidposition,denedjawline,limitedskinexcess,limitedjowling,limitedadipose;preoperativephotos;postoperativephotos.Clinicalphotographsofmorechallengingpatientwhoexhibitsanatomiccharacteristicsfavorableformoretraditionallongincisionrhytidectomy,thatis,unfavorablechinprojection,unfavorablehyoidposition,lessdenedjawline,moderateskinexcess,signijowling,signicantadipose;preoperativephotos;postoperativephotos.FacialPlasticSurgeryVol.30No.4/2014 TheDifficultNeckinFaceliftingFedoketal. 439 Theseshortscartechniquesappeartohavedevelopedtoaccommodatepatientsanatomiccharacteristics,theirdesireforless-invasivetechniques,andeconomics.39,42,43Thereis,atleast,reasonablevalidityfortheapplicationofthesetechniquesinproperlyselectedpatients.Ingeneral,theshort-scartechniquesappeartobebestappliedtothosepatientswhorequirealesserdegreeofskinmanagementandhavefavorableskeletalfeatures.Incontrast,thepatientwithdifcultneckanatomyisfrequentlybestmanagedwithamoretraditionalapproach(Fig.1DesirableResultinFaceliftingTheaestheticneckhasawell-denedjawline,apleasingandadequatecervicomentalangle,andvisibledenitionsofthedeeperlateralandmidlinestructures,suchasthesternoclei-domastoidmusclesandtrachea.44,45Theremustbeenoughsubcutaneousadiposetocreatesmoothcontoursasonetransitionsfromonestructuretotheother;therecannotbetoolittleadiposethatthenecklooksskeletonized,norexcessthatpreventstheappreciationofdeeperstructures.Thereshouldbeanabsenceofplatysmabands,aswellasskinlaxitywrinklesandfolds(Fig.2Theachievementofadesirablesurgicalresultisrelatedtothepatientsunderlyingattributesandtheabilityofthesurgeontocorrectorrestorethepatientsanatomytothatwhichimpartsthecharacteristicsoftheidealneck.Patientsthatbringth
ebestattributestothesurgicaltablecangener-allybeexpectedtogetthebestresults.Theidealpatienthasanatomicattributesthathavemanyorallofthecomponentsofidealestheticneckanatomy.Thosepatientswithmoreanatomicdecienciesaremostlikelytohavemoredifcultyachievinganidealresult.PertinentAnatomyoftheChallengingNeckExcessadiposetissueintheneckleadstotheappearanceofheavyneckandpresentsachallengeinneck-liftingsurgery.Distributionoffatinthecervicalareacanbedividedintothreeregionsandcanbeeithercongenitaloracquired.Adiposetissuecanbediffuselydistributedinthesupra-platysmallayerthroughoutthecervicalregion.Asubmentalfatcollectionbetweentheanteriorbelliesofthedigastricmaybelocatedsubplatysmalandoverlyingthemylohyoidmuscle.Lastly,adiposetissuemaybecomedisplacedasresultofthelaxityoftheplatysmaandattenuationofthemandibularligament,creatingaptoticjowlwithlossofdenitionoftheinferiormandibularborder.Inadditiontoadiposetissue,prominentanteriorborderofthedigastricsandptoticsub-mandibularglandsmayalsodetractfromidealcervicalcontoursandcontributetotheappearanceoftheheavyneck.Skinlaxitywithaccumulationofsubcutaneousfatcanproduceturkeygobblerdeformity,makingtheneckappearheavy(Fig.3Thetwobelliesoftheplatysmamuscle,whichliedeepinthesubcutaneoustissue,originatefromthefasciaofthe Fig.1ContinuedFacialPlasticSurgeryVol.30No.4/2014 TheDifficultNeckinFaceliftingFedoketal. pectoralismajorandascendverticallyintothenecktoinsertattheinferiormandibularborder.Theplatysmacommuni-cateswiththeSMASofthefaceandisinvestedonbothsidesbythesupercialcervicalfascia.Withaging,theplatysmabecomesatrophicandtheplatysmalslingisnolongerabletosupporttheunderlyingcervicalcontents,leadingtosubmen-talsofttissueconvexity.Lossoftonealsoresultsinplatysmabanding,wellknowntobeassociatedwithsignsofaging.Theinterdigitationpatternoftheplatysmacontributestothedenitionofthesubmentalneckcontouratthelevelofthehyoidandneedstobeconsideredinsurgicalplanningforpatientsseekingneck-liftingsurgery.Itisimportanttonotethattherearethreeanatomicvariationspertainingtodecus-sationoftheplatysma;in10%ofthepopulationthereiscloseapproximationbetweenthetwobelliesoftheplatysmawithnodecussation;in75%ofthepopulationthereispartialdecussationinthemidline;andintheremaining15%,totaldecussationfrommandibletohyoidispresentbetweenthetwobelliesoftheplatysma.Whenthemusclesdecussateinthemidline,aneffectivesupportiveslingexistsinthesub-mentalarea.Whenthedecussationisabsent,thefreemedialedgesfallawayfromthesubmentalarea,andthepatientispronetoformtheanteriorneckdeformityknownasverticalbands.Addressingtheplatysmaiskeyinobtainingawell-nedneckandjawline.Thechinprojectionandhyoidpositiondeterminethecervicomentalangle,whichshould
ideallyrangefrom90to105degrees.Thehyoidboneintheadultisideallypositionedatorabovethelevelofthefourthcervicalvertebra.Bothanteriorposteriorandsuperiorinferiorpositionalvariationsofthehyoidareofanalyticalandprognosticvalueincervicalrejuvenation.Alowandanteriorlypositionedhyoidwillproduceanobtusecervicomentalangelbypullingthesupra-hyoidmusculatureinamoreverticalcourse.Unfortunately,suchanatomywillimposesignicantlimitationsonwhatcanbeachievedbytypicalcervicofacialrejuvenationmethods.Patientswithweakorsmallchinscancreateachallengeinneck-liftingsurgery.Underprojectionofthechin,asinretro-gnathiawithAnglesclassIImalocclusion,cancontributetoatruncatedjawline.Microgenia,whichdescribesanunder-projectedmentumindependentofocclusalconsiderations,cansimilarlyaffectthejawline.Theidealprojectionofthechinhasbeendescribedbyseveraldifferentmethodsofassessment.Inmen,thepogonionisideallytangenttoalinedrawnverticallyfromthelowervermilionborderofthelip,andinwomenthepogonionideallyfallsslightlyposteriortothisline.InasimilaranalysisdescribedbyGonzalez-Ulloa,averticallineperpendiculartotheFrankfurthorizontalplaneintersectsthenasion,andthechinshouldbeatorjustposteriortothisline.Althoughmicrogeniaismostcom-monlycongenital,mandibularhypoplasiasecondaryto Fig.2(A,B)Clinicalphotographofapatientwithfavorableneckanatomicfeaturesincluding:awell-denedjawline,anadequatecervicomentalangle,andvisibledenitionsofthedeeperlateralandmidlinestructures. Fig.3AxialMRIimageofpatientsneckpositionedbelowthemandibularbodydepictingsubplatysmalandsubcutaneousfat,sub-mandibularglands,andanteriorbelliesofdigastricmuscles.(MRIimagecourtesyofSangamKanekar,MD,DepartmentofRadiology,UniversityHospital,TheHersheyMedicalCenter,ThePennsylvaniaStateUniversity.)FacialPlasticSurgeryVol.30No.4/2014 TheDifficultNeckinFaceliftingFedoketal. 441 absorptionofalveolarbonewithaging,resultsinformationofprejowlsulcus.Ahigh-positionedhyoidcomplexandwell-denedfacialbonycharacteristicscompriseananatomicallyidealpatientfornecklifting.Inaddition,goodskintone,lackofmajorplatysmalaxityorbanding,andabsentsubmentalfatcancontributetooptimalsculptinganddenitionofthejawline.Unfortunately,certainanatomicvariationscancreatechal-lengesincervicalrejuvenation,makingtheidealjawlinedifculttoestablish.Specicconstraintssuchastheheavyneck,lowandanteriorhyoidposition,lackofchinprojection,anddecientplatysmatoneareaddressedhereinthescopeofcervicalrejuvenation.Lastly,theskinrepresentsthemostconspicuousmarkeroftheagingneck.Withaging,thecollagenandelastinbersdegenerateandtheskinisnolongerabletoadheretosofttissuecontoursoftheneck.Redundancyandsaggingoftheneckskinleadstoeffacementofthecervicomentalangleandcervic
alrhytids,whichcancontributetotheappearanceoftheheavyneck.Lossoforganizationofcollagenbersalsoreducestheskinsabilitytoconform,tighten,andcontractinresponsetosurgicalmaneuvers.TheDifcultNeckBetweentheextremesoftheperfectresultinrhytidectomy,seeninthepatientwithidealcharacteristics,andtheunac-ceptableresultinthepatientwhowasapoorcandidateandaddressedwithpoortechnique,liesagroupofpatientswhopresentconsiderablechallengesbutcanbeconsideredcan-didatesforanacceptableresult.Thedifcultneckisonethatthesurgeonstrivestogetagoodresultinspiteofhavinglessthanidealanatomiccharacteristics.Thesepatientswillachievetheseresultsthroughthebestanalysisoftheirdecienciesandtheapplicationofthebestmethodstocorrectthesedeciencies.Acceptableresultsalsorequiregoodpreoperativecommunicationwiththepatientaboutthelimitationsinherentintheiranatomyandtechnique.Commonissuesthatpresentchallengesincludethefol-lowing:largeamountsofinelasticskin,theheavyneck,platysmabands,microgenia,hyoidmalposition,ptoticsub-mandibularglands,anddigastrichypertrophy.Rhytidectomyinthemalepatientalsopresentschallengesduetothecharacteristicheavierskinofthebearded.48,49Thefocusinthispaperwillbemainlyonpatientswithaheavynecksecondarytoanexcessofadiposetissue.Otherissuestobediscussedbrieywillbemanagementofinadequatechinprojection,platysmabands,aswellasanexcessofskin.Ingeneral,thesepatientscanstillbeconsideredreasonablecandidatesforrhytidectomy.Itmustbenotedthatcertainmodicationstothetechniqueneedtobeperformedtoachieveacceptableresults,andagain,thesepatientshavetobecounseledpreoperativelyastoexpectations.Thesemod-cationsintechniqueincludethecorrectionofunderlyingskeletalfeatures,lipectomy,thecreationofsubstantialSMASaps,andwideskinunderminingtorepositionandremoveabundantskin.Noneofthetechniquesisnovelbutinsteadrequireanindividualizationoftechniquetoeachpatient.ChallengesEncounteredandTheirSolutionsSkinTheamountofexcessandelasticityoftheskinshouldbeascertainedasthisdeterminationwillhaveadirectinuenceonincisiondesign,particularlyinthepostauriculararea.Laxityofskin,especiallyofinelasticskin,willhavetobemanagedsimilarlytothatofpatientswiththinnernecks.Ingeneral,patientswithalargeexcessofskinthatisinelasticwillrequirealongerskinincisiontoachievetheappropriatevectorofmovementandremovaloftheskin.Theageofthepatientwillalsohaveanimpacthere;ingeneral,theolderpatientwillhavelesselasticskin,andagain,willrequirealongerincisiontomanageskinexcessandremoval.Asageneralobservation,theheaviertheneckintheolderpatientwithinelasticskin,thelongertheincisionwillhavetobe.Intheyoungerpatientwithelasticskin,ashort-scarapproachcanbeconsidered.Toallowadequateskinredraping,widerunderminingmayalsobenece
ssaryinthepatientwithaheavyneck(Fig.4Theheavyneckisbecominganincreasinglycommonchal-lengeinrhytidectomywithincreasingpopulationweightnorms,aswellaswithlargernumbersofethnicpatientsthatimpartdifferentbodyshapes.Giventheheavynecksecondarytoanexcessofsubcutaneousadiposeandsub-platysmaladipose,patientweightlossdoeslittletoimpacttheshapeoftheneckwithoutsignicantsurgicalinterven-tion.Thepatientpresentswithananatomicsituationinwhichsomeofthemoredesirablefeaturesoftheaestheticneckwillbelesslikelytobeachieved.Thetreatmentstrategyshoulddelineateanapproachinsettingexpectations,aswellasthesurgicalmaneuverstobeperformed.Theamountanddistributionofadiposeshouldbeascer-tainedandwhetherornotthefatissubcutaneousand/orsubplatysmal.Dependingonthelocation,adecisioncanbemadeaboutreductionviadirectlipectomy,asisperformedinthesubmentalarea,orwithliposuction,laser-assistedlipol-ysis,orotheradjuncttechnique.Directsubmentallipectomymayhavetobeperformedinthepatientwithasevereobtusecervicomentalangle.Thelipectomyshouldbeperformedcautiouslytoavoidskeletonizingthesubmentalareaandcreatingacobradeformity.Ultrasonic-andlaser-assistedlipolysisareadvocatedbysomeauthorsbutarenotuniver-sallyacceptedtobesuperiortoconventionalsuction-assistedlipectomyinthisanatomicarea.11,50Theseniorauthor(FGF),todate,hasacceptableresultsfromconventionalliposuctionanddirectlipectomyinthesettingofrhytidectomy.Someoftheunderminingoftheapsmayalsobeaccomplishedwiththeliposuctioncannula,thusallowinggreatermobilityoftheskinapswhilemaintainingsomeofthevascularconnec-tionswithunderlyingstructures(Fig.5SkeletalDeTheskeletalfeaturesareexamined.ThisdeterminationisamongthemostimportantvariablestobeconsideredintheFacialPlasticSurgeryVol.30No.4/2014 TheDifficultNeckinFaceliftingFedoketal. Fig.4Clinicalphotographsanddrawingsdepictingskinincisionsandareasofunderminingforlowerrhytidectomy.(A,B)Clinicalphotographshowingperiauricularposttragalincisionplan.Onthelateral,projectionisdepictedtheextentofa6cmapasmightbeperformedanteriorlyduringashortscarrhytidectomy.Alsoisdepictedthemoreextensiveunderminingandskinelevationanteriorlyandintothenecknecessaryinpatientswithamorechallengingneck.Thepositionofherplatysmabandsismarked.()Drawingdepictingtheindividualizationofincisionsdesignpossibletoallowadaptationtoapatientsanatomy.()Drawingdepictingthemoreextensivesofttissuemobilizationpossiblewithtraditionallongincisiontechniquescomparedwithshortincisiontechniques.FacialPlasticSurgeryVol.30No.4/2014 TheDifficultNeckinFaceliftingFedoketal. 443 establishmentofanacceptablejawlineandcervicomentalangle.Theunderlyingskeletalfeaturesarethefoundationuponwhichtheoverlyingsofttissuescanberedrapedandreposit
ioned.Theunderlyinganatomycreatestheform;theskinservesasthecover.Throughrelativelysimplemaneuvers(e.g.,genioplastyandtheuseofotherimplants),theskeletalfeaturescanbesignicantlyimproved.Inthesituationoftheheavyneck,thisimprovementoftheskeletalfeaturesmaybeevenmoreimportanttoimpartdenitionalongthejawline.Wherepossible,microgeniashouldbecorrected.Inaddition,thecontourofthejawlinecanbeaugmentedwithinjectablellersandimplants(Fig.6cialMusculoaponeuroticSystemTheconsiderationandmanagementoftheSMASorlayerisamongthemostimportantaspectsofrhytidectomy.Foranin-depthreviewofthistopic,thereaderisreferredtootherreferences.20,24,31,32,34,36,42,43,51Inexaminingthetop-ic,whatbecomesveryclearisthatthereisavarietyofmethodsadvocatedtotighten,lift,advance,andpositionthisveryimportantlayer.ThemethodsadvocatedrangefromthosethatsuperciallyandinalimitedfashionplicateandimbricatetheSMAS,tothosethatinvolveamoreextensiveapdevelopmentwithamultivectortion,tothosethatadvocateadeepplanedissection.Whilethereislimitedconsensusaboutwhichtechniqueshaveagreaterlong-termadvantage,thereappearstobeageneralconsensusthatthevectorofadvancementshouldbepos-teriorandsuperiortofavorablyaffectthemidface,thejowls,andtheneck.ThereisalsobroadagreementthatsomeformofSMASmanagementshouldbeconsideredinmostrhytidectomycases.Theseniorauthorhasutilizedseveralofthesemethodsacrosspatientswithvaryingcharacteristics.Ingeneral,forthemorechallengingneck,andparticularlytheheavierneck,amoreextensiveSMASapisdevelopedtomobilize,advance,andsupporttheheaviertissues.Theexacttechniqueusedisindividualizedtotheparticularpatient(Fig.7PlatysmaBandsThepresenceofplatysmabands,whilelessvisibleinthesepatientswithheaviernecks,willstillhaveanimportantimpactonthenalresult.Inaddition,andpossiblymostimportantly,thecervicomentalanglemustbeoptimizedifpatientswithheavynecksaretobeofferedthebestpossibleresultswithrhytidectomy.Platysmaplastyshouldbedonewhenthereisevidenceofplatysmabands,asthiswillbenecessarytoimprovethecervicomentalangle.Similartoothersituationswhenthemidlineplatysmaaresuturedtogether,evenwiththeheavyneck,optimalskinredrapingmayrequirethedevelopmentofalongapforunderminingfromeartoear.Insomepatientswithparticularlyheavytissues,aformofaslingorasuspen-sionisadvocatedtomaximizethecervicomentalangle.9,44,60SecondaryProcedureAdequatepatientcounselingrequiresinformingthepatientthattheymayrequireasecondaryprocedureortuck-upapproximately1yearaftertheirprimaryproceduretoopti-mizetheirresult(Fig.8FurtherAdjunctsandTechniquesUseofFatandFillersAsthefocusofthispaperislargelyonthepatientwithaheavierneck,theuseofllersislimitediftheconsiderationisthesofttissuesoftheneck.Incontrast,llerscanbeusedtoll
indecienciesofthemandibleandcreateimprovementinthegeniomandibulargrooveandangle.Theuseofinjectablellersorstructuralfatgraftingtoimprovetheappearanceofvolumelossintheagingfaceand Fig.4ContinuedFacialPlasticSurgeryVol.30No.4/2014 TheDifficultNeckinFaceliftingFedoketal. neckhasbeendescribedandhasdemonstratedsomesuc-cess.Theuseofinjectablellermaterials,suchashyalur-onicacid,human-derivedcollagen,calciumhydroxyapatite,polymethylmethacrylate,andpoly-L-lacticacidhavelongbeenregardedfortheiruseinthecorrectionoftissueatrophyrelatedtofacialaging.Theyhaverapid,predictableresults,demonstratearelativeeaseofdelivery,andhaveafavorablesafetyprole.Oneofthemostcommonapplicationsoffacialllersinthetreatmentoftheagingneckistoimprovetheappearanceoftheprejowlsulcusandthejawline.Therehavebeenreportsofsuccessfulresultsintheliteraturewithboththeuseofhyaluronicacidllersandpoly-L-lacticacid.Whilethesellersaregenerallyquitesafe,itisimportanttobefamiliarwiththeirpotentialcomplicationsandtheirmanagement.Althoughrare,complicationssuchascellulitis,granulomaformation,orskinnecrosishavethepotentialtocausesevereandpossiblypermanentscarring.Autologousfattransferhassimilarlybeendescribed.Contouringtheprejowlsulcusisconsideredoneofthemostimportantapplicationsofautologousfattransfer.63,66Onetechniquedescribedintheliterature,whichhashadsuccess,makesuseofthreesitesforinjectionoftheautolo-gousfat:alongtheanteriorsurfaceofthemandiblealongtheperiosteum,alongtheinferiorsurfaceofthemandibleandtowardthedigastricmuscle,andlastly,obliquelybetweenthosesitesinthesupercialtissues.Thepossibilityoffatresorptionremainsamajorconcernwiththeuseofautolo-gousfattransfer,andchangesintheappearanceofthefatarealsopossibleifpatientsundergoanysignicantweightlossorgainaftertheirprocedure.Arecentstudy,forexample,foundthatonly31.8%oftheoriginalvolumereplacedwasretainedat16monthsposttreatmentwith24%ofpatientselectingtoundergoadditionalfattransferwithintheyear.Resurfacing,Lasers,andChemicalPeelsThequalityandtextureoftheneckskinisanimportantcomponentintheappearanceofayouthfulneck.Changesinskintexture,skinlaxity,andthepresenceofrhytidsallcontributetotheappearanceoftheagingneck.Patientsoftenpresentwithdermalchanges,suchasirregularpigmentation,lentigines,keratosis,wrinkling,andstriaedistensae,whichareamenabletotreatmentwithresurfacing.Therearede-scriptionsofvariousresurfacingmodalitiesintheliteraturethathavebeenusedsuccessfullytoimprovethesesignsofagingintheneck,includingdermabrasion,chemicalpeels,andlaserresurfacing.Theuseoflaserswithdifferentwavelengthsallowsonetotargetdifferentchromophores,suchaswater,melanin,orhemoglobintoachievethedesiredclinicalresult.Thelasersmostcommonlyusedf
orresurfacingoftheneckincludethe Fig.6Clinicalphotographdemonstratingtheimprovementofthispatientsskeletalfeatureswithchinaugmentationthusfacilitatingthecreationofadesirablementocervicalanglewithrhytidectomy()Priortochinaugmentationandfacelift.()Postoperativephotographafterchinaugmentationandfacelift. Fig.5Clinicalphotographsoffatremoval.Directsubmentallipectomy.(B)Suction-assistedlipectomycarriedthroughsubmentalincisiontodebulkthesubmentalareaandunderminetheskinmorelaterally.(C)Opensuctionlipectomytofacilitateandextendundermining.FacialPlasticSurgeryVol.30No.4/2014 TheDifficultNeckinFaceliftingFedoketal. 445 laserandtheerbium:yttrium-aluminum-garnetlaser.Thetargetedchromophorefortheselasersiswaterlocatedinthedermis.Astudyof10patientswhounderwentbetweenoneandthreesessionsofnonablativeCOlaserresurfacingoftheneckfoundsignicantimprovementsintheappearanceofskintexture,skinlaxity,andrhytids,withanaverageof1.4sessionsrequiredwithnoreportsofadversereactionorcomplication.Laserresurfacingoftheneck,however,shouldbeperformedwithcautionascomplicationsmayoccur.Anothermethodforresurfacingthenecktoimprovethesignsofagingistheuseofchemicalpeels.Althoughnotaswelldescribedintheliteratureastheuseofchemicalpeelsforthefacialskin,someauthorshavereportedsuccessaddressingskintexture,irregularpigmentation,rhytids,lentigines,andactinickeratosiswithchemicalpeelingoftheneck.Again,cautionisadvocatedsoastoavoidcomplications.Thefollowingpatientspresentedwithanatomicchal-lengesmanagedwiththetechniquesdescribed.Patient1Thispatientpresentedwiththefollowingcharacteristics:excessivethickinelasticskin,moderateadipose,signicantjowling,andplatysmabands(Fig.9Patient2Thispatientpresentedwiththefollowingcharacteristics:excessivethickinelasticskin,moderateadipose,signicantjowling,andminorwideplatysmabands(Fig.10Patient3Thispatientpresentedwiththefollowingcharacteristics:excessivethickinelasticskin,moderateadipose,signicantjowling,minorwideplatysmabands,skeletaldeciencywithmarkedmicrogenia.Thispatientshistorywascomplicatedbyapastleftneckdissection(Fig.11 Fig.8Clinicalphotographsofpatientwithdifcultneckanatomywhohadundergonepreviousshortscarlowerfaceliftatanotherofce(within24months)andimprovementafterin-ofcetuck-upprocedureinvolvingminimalskinexcisionandpurse-stringtighteningofsupermusculoaponeuroticsystem.(A,B)Beforetuck-up.(C,D)Aftertuck-up. Fig.7Clinicalphotographdepictingelevationofsupercialmuscu-loaponeuroticsystemFacialPlasticSurgeryVol.30No.4/2014 TheDifficultNeckinFaceliftingFedoketal. Fig.9Clinicalphotographswiththefollowinganatomicchallengingcharacteristicwhopresentedforfacelift.Signicantexcessivethickinelasticskin,moderateadipose,signicantjowli
ng,andplatysmabands.Operativeapproachincludedthefollowing:traditionallongincisionswithpostauricularextension,wideunderminingacrossneckwithreleaseofmandibularligament,liposuction,managementofplatysmawithanteriorsuturingandlateralsuspension,supercialmusculoaponeuroticsystemwasmanagedbycreationoflimitedapandimbrication.Preoperative.Postoperative. Fig.10Clinicalphotographswiththefollowinganatomicchallengingcharacteristicwhopresentedforfacelift.Signicantexcessivethickinelasticskin,moderateadipose,signicantjowling,andminorwideplatysmabands.Operativeapproachincludedthefollowing:traditionallongincisionswithpostauricularextension,wideunderminingacrossneckwithreleaseofmandibularligament,liposuction,managementofplatysmawithlateralsuspension,supercialmusculoaponeuroticsystemwasmanagedbycreationofextendedapandimbrication.Preoperative.Postoperative.FacialPlasticSurgeryVol.30No.4/2014 TheDifficultNeckinFaceliftingFedoketal. 447 SummaryThedifcultneckisonethatthesurgeonstrivestogetagoodresultinspiteofthepatienthavinglessthanidealanatomiccharacteristics.Acceptableresultscanberealizedthroughthebestanalysisoftheirdecienciesandtheapplicationofthebestmethodstocorrectthesedeciencies.Themethodsemployedarethosethatarebasedonestablishedprinciplesandapplication.Inthecaseofthedifcultneck,theapplica-tionisindividualizedandappropriatelymodiedtothepatientsanatomy.AcknowledgmentTheauthorswholeheartedlythankKimGordonforedito-rialassistance.ReferencesAAFPRS.2012AAFPRSMembershipStudy.InternationalCommu-nicationsResearch.Media,PA2013McColloughEG,HaCD.TheMcColloughFacialRejuvenationSystem:expandingthescopeofacondition-specicalgorithm.FacialPlastSurg2012;28(1):102115LangsdonP,ShiresC,GerthD.Lowerface-liftwithextensiveneckrecontouring.FacialPlastSurg2012;28(1):89101MarchacD.JulienBourguet.Thepioneerinaestheticsurgeryoftheneck.ClinPlastSurg1983;10(3):363365SkoogT.Plasticsurgery:theagingface.In:SkoogTG,ed.PlasticSurgery:NewMethodsandRenements.Philadelphia,PA:WBSaunders;1974:300330MitzV.Thesupercialmusculoaponeuroticsystem:aclinicalevaluationafter15yearsofexperience.FacialPlastSurg1992;8(1):11MitzV,PeyronieM.Thesupercialmusculo-aponeuroticsystem(SMAS)intheparotidandcheekarea.PlastReconstrSurg1976;58(1):80MillardDRJr,GarstWP,BeckRL,ThompsonID.Submentalandsubmandibularlipectomyinconjunctionwithafacelift,inthemaleorfemale.PlastReconstrSurg1972;49(4):385391ConnellBF.Contouringtheneckinrhytidectomybylipectomyandamusclesling.PlastReconstrSurg1978;61(3):376383CourtissEH.Suctionlipectomyoftheneck.PlastReconstrSurg1985;76(6):882889GrottingJC,BeckensteinMS.Cervicofacialrejuvenationusingultrasound-assistedlipectomy.PlastReconstrSurg2001;107(3):847855Gryskiewicz
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