9 Direct-Excision Techniques
Direct-excision techniques for managing the neck have a long history in cosmetic rejuvenation surgery. They offer an alternative or adjunct to facelifting, liposuction, and platysmal imbrication. Their usefulness is manifold and they provide an alternative to more aggressive approaches to rejuve-nation of the face. Direct excision is appropriate for patients with isolated cervical laxity, medical conditions contraindicating more prolonged procedures that may require deeper anesthesia, and isolated submental failure after rhytidectomy, as well as for the patient disinclined to undergo a facelift ( Fig. 9.1 ). Moreover, direct-excision techniques can create a defined cervicomental angle (CMA) that is difficult to obtain with any other technique ( Fig. 9.2 ).
Proper patient selection and education are imperative for direct-excision surgery just as for all procedures to improve the neck. Such surgery can address fullness, laxity, and banding in the neck. However, it does not improve the jaw line and may even worsen the appearance of an undulating jaw line by creating a regional discrepancy between the rejuvenated neck and the face. For this and other reasons, direct-excision surgery must be applied appropriately. Simple linear excision,1–3 the lazy H,4 T-Z plasty,5 running W-plasty,6 and Grecian urn techniques7,8 have all been described as ways to approach the “turkey gobbler” neck or “wattle.” Each procedure has its benefits and drawbacks.
The problem that needs to be addressed by plastic surgery of the neck may be laxity, fullness, or platysmal banding, alone or in combination, and is compounded by a fixed structure in the mandible superiorly and the visibility of the vertical segment of the surgical scar beneath the hyoid bone inferiorly. The mandibular margin at the chin prevents the smooth tapering of any linear vertical excision when immediate submental laxity, skin redundancy, is present. Moreover, with vertical excision, a standing cutaneous cone can be created at the menton. The segment of the vertical excision inferior to the CMA may be visible and must be camouflaged.
The CMA is defined by the position of the chin, hyoid bone, degree of laxity of cervical skin, submental adiposity, and relaxation of the platysma muscle. Abnormalities in any of these factors can create an obtuse CMA. However, although such abnormalities can occur in isolation, they are most often seen in combination. With the exception of the position of the hyoid bone, the perception of all of these abnormalities can be addressed with direct excision.
◆ Choosing a Technique for Direct Excision
To achieve the goal of an improved CMA, reduced skin laxity, and refinement of the contour of the neck, the surgeon must define the pathology that requires correction and the best approach to accomplishing this. Submental laxity of skin and adiposity can extend superiorly to a level immediately adjacent to the menton, usually stopping at the submental crease, but sometimes extending inferiorly to the clavicles and manubrium. Some degree of sagittal excision of skin must therefore be done immediately adjacent to the mandible superiorly, and possibly also at the inferior extent of the excision at or below the position of the cricoid cartilage.
With vertical linear extension of the incision for skin excision there will be a tendency to create a standing cutaneous cone or cones of midline skin at the superior, menton, and inferior, cricoid or thyroid cartilages, extent of the excision. This can only be avoided by incorporating an A-T closure or W-plasty at the submental crease, to keep the incision from crossing the mandibular margin at the menton. With the vertical elliptical excision of skin, the inferior limb of the transverse elliptical excision at the submental crease must be lengthened.6 This can be done by having the incision take the form of an arc half the length of the transverse submental incision. Doing this makes each side of the transverse submental excision of equal length, with the goal of avoiding bunching of skin upon closure of the incision, and it shortens the vertical dimension, length, of the ellipse of skin which is to be excised, with the goal of avoiding vertical banding in the neck.
The vertical shortening of the transverse ellipse in the skin of the neck is resolved with the addition of tissue through the creation of transposition flaps in the form of a Z-plasty7 at the level of the hyoid bone. This both increases the extent of vertical soft tissue at the site of the excision and breaks the linearity of the incision following its closure, which helps to camouflage the incision scar.
When the vertical elliptical excision of skin from the neck is given the respective stopping points of transverse elliptical excisions superiorly at the submental crease and inferiorly at sites of orthostatic rhytids in the neck, the shape of the area of surgery on the neck is that of a Grecian urn, with a Z-plasty at the desired level of the CMA.
When the laxity of cervical skin is limited to the immediate submental area, as can occur after a facelift, and especially after a limited procedure, an A-T plasty or direct linear excision of excess skin can be appropriate, but the excision must remain above the CMA. No linear excision should cross the CMA because this carries the risk of contracture and webbing. Lengthening and release of the linear incision with a Z-plasty is done to avoid these risks ( Fig. 9.3 ).
The use of bilateral advancement flaps, as in the H excision, to correct the defect created by the excision of midline skin, will leave a combined length on the excisional side of the submental and inferior incisions that is less than the length of the incision on the non-excisional sides of the transverse incisions.
The transverse H or lazy H excision technique4 fails to address the problem created by the lengths of the transverse components of the incision in the submental area and inferiorly. This discrepancy will create a standing cutaneous cone in the superior and inferior distal skin.
◆ Addressing the Problems Requiring Direct-Excision Surgery
The submental wattle or turkey-gobbler deformity of the neck most often has multiple components including muscle, fat, and skin, and occasionally retrognathia or micrognathia. Success in treating such a deformity requires addressing each of these components. This can be achieved with any direct submental approach. The excess skin of the deformity is simply removed through excision, and the fat is removed through direct excision occasionally supplemented with lateral liposuction and re-creation of the natural sling provided by the platysma muscle through division of the platysma and its tightening and repair with a “pants-over-vest” imbrication. This combination of procedures will address all components of a submental wattle or turkey-gobbler deformity with the exception of the position of the hyoid bone.
To address the abnormalities included in Dedo’s six-level classification of cervical deformities,9 the surgeon need only vary the extent to which each component of the direct-excision procedure is modified. When adiposity is the primary concern and skin tone remains excellent, liposuction alone may achieve the desired sculpting of the CMA. When skin laxity exists, some degree of excision will be required. Skin tightening with radiofrequency heating or other presumably noninvasive percutaneous techniques is usually inadequate, but can be performed with liposuction which may produce a subtle cosmetic improvement. In the patient with platysmal dehiscence, the muscle must be tightened. This is easier to do with an open technique. Tightening of the platysma will, however, necessitate skin redraping or excision.
Most direct-excision techniques have potential pitfalls that need to be addressed. The lazy H4 and vertically running W-plasty6 fail to address disparities of length in their horizontal segments; the superior and inferior transverse incisions in these procedures are longer at the distal limit of the vertical elliptical excision, creating a standing cutaneous cone. To avoid this, the proximal segment of the transverse excision must be lengthened. This can be accomplished with an A-T plasty having an arch in the proximal segments of its transverse incisions. Yet this can still carry the risk of banding of the linear vertical segment of the treatment area. This can be avoided through the use of a Zplasty, centered at the desired cervical mental angle, which is usually at the level of the hyoid bone, creating a T-Z-plasty as described by Cronin and Biggs.5 A standing cutaneous cone may be created at the inferior extent of the vertical excision of skin from the neck, which can exacerbate the male thyroid notch or create the illusion of a thyroid notch in the female. This is best avoided by extending the vertical excision beyond any inferior redundancy and stopping at an orthostatic rhytid, with the mirror image of the submental transverse excision addressing disparities in length of the proximal and distal transverse segments of the excision ( Fig. 9.4A ). This designed excision, addressing all disparities and concerns, produces a cutaneous excision resembling a Grecian urn with a central Z-plasty, as originally described by Farrior.7