8 Variations in Platysmaplasty: Pursestrings, Slings, and Nonabsorbable and Bioabsorbable Structural Techniques
A slender and well-defined neckline is recognized as an attractive feature of youth. Chronological aging is accompanied by changes in the neck that result in blunting of the cervicomandibular angle, the accumulation of subcutaneous adipose tissue, laxity of the submandibular glands, and changes in the platysma muscle that include laxity and anterior shifting that results in “banding” ( Fig. 8.1 ). Anterior shifting of the platysma, which contributes to an increasingly obtuse cervicomandibular angle, becomes a key component in aesthetic improvement of the neck. Changes in skin texture and increased laxity add to the manifestations of aging in the neck.
The past 50 years have seen many new techniques introduced for treating aging of the lower face and neck, beginning with Johnson and Hadley’s1 recommendation for the direct excision of soft tissues and fat of the neck for treating a blunted or obtuse CMA. Their approach also addressed platysmal banding through the use of incision and Z-plasty. Weisman2 suggested that rejuvenation of the neck should include submental lipectomy followed by platysmal myotomy and Z-plasty. Milliard et al3 emphasized myectomy and lipectomy in rejuvenation of the neck. Guerro–Santos4 introduced lateral imbrication of the platysma to the fascia of the SCM and mastoid periosteum in 1978. In the same year Connell5 described an anterior platysmaplasty with direct approximation of the platysmal heads in the midline. Liposuction as an alternative to submental lipectomy of the neck was introduced by Illouz6 in 1982. The 1990s brought several innovations, with corset platysmaplasty introduced by Feldman,7 suture suspension techniques,8 suture and extended polytetrafluoroethylene (ePTFE) slings,9,10 and platysmal overlapping techniques.11 Most of the techniques described for rejuvenating the neck rely on two-dimensional medial-to-lateral vectors of repositioning, representing a “side-slinging” of the platysma. Because the platysma is an extremely thin muscle, it is somewhat incompetent for reinforcing the deeper tissues of the neck in procedures for substantial rejuvenation of the neck. Nahai12 addressed the shortcomings of some platysmal suspension techniques, noting that he had restricted his use of suspension sutures because patient follow-up over time had demonstrated that confining the surgical focus to the superficial neck planes did not produce long-lasting correction. He found that appropriate contouring of fat and tightening of muscle combined with subplatysmal procedures produced better and longer-lasting results.
This chapter discusses in detail technical adaptations for reinforcing various techniques for platysmaplasty, which take slightly different approaches to produce more durable and longer lasting results in aesthetic rejuvenation of the aging neck.
◆ Structural Modification Techniques and Terminology for Modifying the Platysma Muscle
Over the past 20 years a variety of different techniques have been described for rejuvenation of the neck with or without concurrent rhytidectomy. In understanding how these techniques should be described or evaluated it is important to understand the biomechanics of the way in which a technique improves or interacts with the aging neck. Some techniques that have been described as suture suspension techniques are actually suture sling techniques, and to better understand how these techniques work we will first define the various techniques and how they are directed at rejuvenating the aging neck.
Most of the techniques described for rejuvenation of the neck include some repositioning of tissues, with their elevation to a different level effecting the aesthetic improvement in an aging neck that addresses the patient’s concerns. The simple approximation or “bringing together” of tissues so that they are “located close together” is seen in medial platysmaplasty. Medial platysmaplasty is the technique of bringing together the two medial heads of the platysma muscle ( Fig. 8.2 ). The usual technique of medial platysmaplasty is to approximate the medial borders of the muscle with simple or running sutures.The undermining of the medial borders of the platysma and their bringing together so that they overlap would not be classified as approximation but would be an imbrication, as described below.
Plication is often utilized in rejuvenation of the face and neck. The structures most commonly plicated are the superficial musculoaponeurotic system (SMAS) and the platysma muscle complex. To plicate means to fold over or to pleat, much in the same fashion that curtains are pleated to convert a very large surface area into a smaller surface area. Sutures that when pulled together reduce the surface area of the SMAS–platysma complex are plication sutures, and include the lateral pleating sutures in Feldman’s corset platysmaplasty and the sutures used in the S-lift13 and in Tonnard’s14 modification of the S-lift, the minimal-access cranial-suspension (MACS) lift.
Imbrication is another technique often used in rejuvenation of the face and neck. In contrast to techniques for plication, imbrications involve some degree of undermining of soft tissue or more commonly of muscle, and overlapping of these structures, which as in the case of plication will also decrease the surface area of the treated anatomical unit. Alternatively, imbrications involve the raising of soft tissue or a muscle to a new level or position, as is typically done in rejuvenation procedures based on a flap of SMAS–platysma complex.
Suture suspension techniques are used in conjunction with both plication and imbrication techniques. The term suspension implies that the anatomical unit being referred to is undergoing repositioning to a new and usually higher level than its previous level. The most common anatomical unit to be suspended in rejuvenation surgery of the face and neck is the SMAS–platysma complex. According to the terminology and definitions given earlier in this chapter, undermining and overlapping of the structure being treated with suture suspension constitutes a suture-suspension imbrication, which was first reported for rejuvenation of the neck in the platysmaplasty procedure described by Owsley.15 Simple stretching or folding of the tissue being treated, without undermining it, would qualify as a suture suspension plication.
In some rejuvenation techniques, and in addition to plication or imbrication of the SMAS–platysma complex with or without its suspension (moving it to a higher level or repositioning it), a suture or a wider structure (expanded polytetrafluoroethylene [ePTFE]) implants may be placed for the purpose of supporting or cradling the SMAS–platysma complex. Usually the muscle being cradled by such a structure consists of one or both heads of the plastysma muscle just below the mandibular border, and the associated deeper cervical structures. A sling can also support or cradle a structure that has also been plicated or imbricated, and the definition of a sling implies that the suture or wider unit constituting the sling itself adds intrinsic and extrinsic support to the region in which it is located. According to Giampapa’s8 definition of his suspension sutures in his technique, they are also plicated slings. Guerrero–Santos4 is also credited with the description of sling sutures. In most of these techniques the suture is not placed into the platysma muscles but simply spans it in a supportive manner. The use of ePTFE slings is described in more detail below.