Keeping the neck at face value

St. Louis - Patients are always looking for the latest ways to keep their faces looking young.

But the best facial rejuvenation techniques can be diminished if the face appears to grow younger while the neck on down continues to look older.

A variety of methods are available and at the recent American Society for Dermatologic Surgery meeting in Atlanta, Roberta Sengelmann, M.D., who is assistant professor of dermatology and otolaryngology, and director, Center for Dermatologic and Cosmetic Surgery, Washington University School of Medicine, St. Louis, outlined one surgical technique she likes to use to rejuvenate the neck.

Working the neck

The neck lift Dr. Sengelmann employs starts with tumescent liposuction ofthe neck and jowls. She generally uses0.2 percent lidocaine with epinephrine, 1:500 K to achieve local anesthesia.

To perform the liposuction, Dr. Sengelmann uses several 2 mm to 3 mm entry sites.

One goes underneath the chin and the others are placed as needed - such as the intralobular neck and sometimes right under the jowl itself, or at the angle of the mouth to better access the jowl fat. Blunt 12 g to18 g cannulas are used to greatly aspirate excess fat in these areas.

Next, she makes a curvilinear incision measuring approximately 2 cm to 3 cm in length and curved to follow the angle of the jaw. From that vantage point, Dr. Sengelmann carries out a dissection in the subcutaneous tissue and over the platysma.

The skin and fat are elevated from the submentum all the way down to the base of the neck and from one medial sternocleidomastoid to the other.

"Once that is done and diligent hemostasis is achieved with bipolar coagulation, I dissect out the medial bellies of the platysma. Oftentimes, once the muscle bellies are identified in the submental area between the muscle bellies, you can actually find a pocket of subplatysmal fat. Careful removal of this fat pad will yield a better neck contour."

Dr. Sengelmann warns that the surgeon must be careful because of the copious vasculature in this area.

"It's critical to have a headlamp and bipolar coagulation with special bayonet forceps, which are long enough and angled correctly so that if you see bleeding far away from the incision, you're able to go in and stop it. A headlamp is critical for adequate visualization through what is essentially a tunnel," she tells Dermatology Times.

Once the subplatysmal fat is dissected and removed, the medial bellies of the sternocleidomastoid muscle are sutured in a corset-type suture with a buried notch in the submental area. This platysmal plication improves the cervicomental angle and allows a lasting improvement in the contour of the neck.

It runs from the submentum to the mid-neck, at least to the level of the hyoid bone, then the surgeon turns around and comes back, further imbricating and tightening the muscle.

"This provides a nice, smooth contour along with a more acute cervicomental angle."

Thereafter, if there is any skin tethering at the edges of the undermining from pulling the neck toward midline, this is freed up.

"After one last look and lavage for bleeders, the neck skin is redraped, the submental incision and liposuction entry sites are sutured, and French tape is placed to suspend the skin into position. A neck garment or cotton/Kerlix (Tyco Healthcare Group) dressing can also be used, but care must be taken not to strangle neck skin. That could lead to cutaneous necrosis, especially along the submental incision."

Dr. Sengelmann notes that post-op pain medicine is generally not necessary. Sutures are removed in five to six days. Patients like this approach to neck rejuvenation because of the limited cost and downtime.