Speaking here at "Plastic Surgery 2005," a conference organized by the American Society of Plastic Surgeons, Oscar Ramirez, M.D., shared knowledge of how to surgically manipulate the subplatysmal plane to achieve a desirable outcome.
Dr. Ramirez is a clinical assistant professor, division of plastic surgery in the department of surgery at the Johns Hopkins University School of Medicine and the University of Maryland School of Medicine. He runs Esthetique Internationale, a private plastic surgery center in Timonium, Md."Unfortunately, we cannot perform surgery that elongates the neck, so we have to work with the areas where we can make improvements or modifications," Dr. Ramirez says. "One of those areas is the skeletal support of the jaw. It can be augmented to improve the aesthetic outcome."
A reduction in the skeletal framework due to aging results in laxity of soft tissues, in particular the deep organs and fat of the neck. Loss of bone support leads to loss of support for the face's soft tissues, he explains.
Dr. Ramirez performs a deep-layer cervicoplasty in about a third of his patients to correct neck contours. This procedure involves removing fat from the subplatysmal layer and between the anterior bellies of the digastric muscles. The digastric muscles are then plicated toward the midline and the platysma muscle is separated from the underlying submandibular gland.
Dr. Ramirez stresses that solely removing the fat and tightening the platysma does not produce a satisfactory visual effect or a lasting one.
"We have to analyze the structure of the bones above the neck and the structures deep to the platysma," he explains. "The mandible has a lot of influence in terms of the appearance of the neck post-operatively. If patients have strong skeletal support, meaning a strong mandible, they then age better and will look better. Having a long neck will make them look better as well. Crowding of tissues is common in patients with short necks."
When patients have enlarged or droopy salivary glands, Dr. Ramirez recommends partial or total excision of the glands to create a smooth appearance of the neck. The excision of the glands can cause the complication of dry mouth in a minority of patients, which is why Dr. Ramirez opts for partial excision of the glands.
"It's a rare side effect," Dr. Ramirez reports to Cosmetic Surgery Times. "It shouldn't be a complication that is very serious since we have plenty of other salivary glands. I would not question a surgeon who performs complete excision of the glands."
The salivary glands that are extracted are typically not functioning well in the patient population that is opting for surgery for improved neck contouring, according to Dr. Ramirez.
"In many older patients, those glands are inflamed," Dr. Ramirez says, noting that patients who choose the procedure are typically 50 and older. "They are suffering from sialadenitis. The patients benefit from excision because those glands are not working well. Partial excision of the digastric muscle may be necessary as an additional procedure to improve the aesthetic outcome."
Not for novice
Dr. Ramirez emphasizes that the procedure is not one that should be performed by an inexperienced surgeon.
"This isn't surgery that can be performed by a novice," he says. "If a surgeon hasn't had any training in head and neck surgery, they need to first practice on cadavers to become sufficiently familiar with the anatomy. There is a potential for significant complications in untrained hands."
Complications that can occur due to the surgery include uncontrollable bleeding and paresis of the lower lip.
To sustain the effect of the procedure, Dr. Ramirez recommends that patients avoid smoking and extended sunlight exposure, and consider the neck when they think of skincare. He estimates the procedure can last anywhere from five to 10 years.