San Diego — Commonly performed as an adjunct to a facelift, submentoplasty can dramatically improve the appearance of a cosmetic surgery patient's neck. While the procedure may be beneficial — especially in patients who have had a poor outcome with liposuction — submentoplasties have always been tricky, due to the small incisions through which they are often performed.
For the same reasons, great caution should be used in performing what could be referred to as a deep submentoplasty, because while the procedure offers a lot of therapeutic options for a cosmetic surgeon, it is not for the inexperienced.
"The submentoplasty is helpful for people who have heavy necks with deep fat, or necks with platysmal banding, as well as necks with ptotic, or enlarged, submandibular salivary glands, which cause bulging on the side of the neck. No matter how good of a facelift you do, you'll still see that bulge if the glands are enlarged," says Angelo Cuzalina, M.D., D.D.S. He spoke on the topic at the American Academy of Cosmetic Surgery (AACS) annual meeting here. He is associate professor in the maxillofacial surgery department at the University of Alabama and the University of Oklahoma."In fact, a lot of times when you pull the skin or SMAS tight, you may see the bulges even more," he adds.
"The gland ptosis or hypertrophy may result simply from genetics, or sometimes as a complication of overaggressive liposuction," Dr. Cuzalina says.
"When someone has simply had a little bit too much fat removed in that area, what results is called the skeletonization of the patient. That's one of the many instances where you might want to consider removing some of the gland. I make an attempt to leave a significant amount of fat on the skin side to prevent irregularities or unwanted dermal fibrosis," he says.
Experience required The deep submentoplasty with partial gland resection is not a procedure for the office surgeon, says Dr. Cuzalina, who has done just over 50 of the procedures in the past three years.
"Once I lift the skin up, I go even deeper into the neck, under the platysmal muscle and deep cervical fascia, elevating posteriorly several centimeters to gain access to the submandibular glands where they can be partially resected," he says. "The procedure is much more advanced than liposuction and you need to know your anatomy very well, since there are certain nerves and blood vessels around that can complicate the procedure, especially since it is performed through a small submental incision."
In particular, Dr. Cuzalina mentions the proximity of a branch of the facial artery and the marginal mandibular branch of the facial nerve.
"If there's bleeding, its going to be difficult to control from the small incision far above it," Dr. Cuzalina says. He adds that he had experienced bleeding in the area before.
"You have to make sure you have good retraction and can see extremely well, and have a very bright light. Sometimes you may actually want to use an endoscope to aid in visualization, and always make sure you do the procedure as bloodlessly as possible," he says.
For patients who choose it, however, the deep submentoplasty offers a number of options.
"You can remove fat, which is superficial or deep to platysma, depending on whether the patient is heavy or thin," he says. "You can also retighten the platysmal muscle itself. The other common thing to do through the same small incision is to place a chin implant, usually made out of solid silicone."
While the procedure can be done on an outpatient basis, Dr. Cuzalina performs it while the patient is under general anesthesia in his surgery center.
Possible problems "You also want to ask them if they have any symptoms of dry mouth, because if they already do not produce much saliva you would not want to remove any portion of the gland. Generally, however, removing as much as 50 percent of the submandibular gland really will not compromise the overall salivary production," he says.