Download Face Lift With Submandibular Gland and Digastric Muscle Resection

My View
Face Lift With Submandibular Gland and
Digastric Muscle Resection: Radical Neck
Rhytidectomy
The author discusses his view that the risks of aggressive subplatysmal surgery are not balanced by substantial benefits. He emphasizes that aesthetic standards for
neck contouring should not be based upon unrealistic
criteria for the “youthful neck” but modified according
to each patient’s unique physiognomy. He stresses the
need for reporting of large case series, standardized
evaluation and surgical technique, and accurate data
on complications of aggressive subplatysmal surgery
before surgeons embrace these radical contouring techniques. (Aesthetic Surg J 2006;26:85-92.)
F
or several years a small group of bold and creative
surgeons have advocated aggressive subplatysmal
surgery to achieve a youthful neck. This includes
resecting subplatysmal fat down to mylohyoid muscle,
resecting the anterior belly of the digastric muscles, and
subtotal resection of the submandibular glands.1-20
The advocates of aggressive subplatysmal surgery state
that their techniques are “…simple, safe, and effective”
for digastric muscle resection,6,7 and “…safe and effective” for submandibular gland resection.20 They emphasize that you must be “…a highly trained, very skilled,
very experienced surgeon” to perform these “…advanced
techniques.”14-17 They claim that their results are better,
more natural, and longer lasting, and that these benefits
justify the risks, potential complications, and longer operating time.
Having never found it necessary in more than 25
years of face lift surgery to perform these techniques to
contour the neck, I find myself asking, “What am I
missing? Why not try it?” The answer is partly that I
am not convinced the results shown are superior to
what I can accomplish with standard, less invasive
techniques. More important, I do not believe the
implied benefits outweigh the increased morbidity and
risks, especially the risk of hemorrhage and an expanding hematoma beneath the deep cervical fascia following submandibular gland resection, a risk that could
AESTHETIC
lead to airway obstruction
and the need for an emergency tracheostomy.21
But then I reflect, “Good
surgeons are advocating
these procedures; they are
my colleagues, and some are
my friends. The results they
show are good.” To satisfy
Daniel C. Baker, MD, New
my curiosity, I went to the
York, NY, is a board-certified
cadaver lab to dissect the
plastic surgeon and an ASAPS
member.
subplatysmal structures and
determine what role they
play in neck contouring. I
also reviewed all the information I could find in the plastic surgery literature about these techniques. Following
are some of my conclusions.
The Youthful Neck
A paper was published in 198022 describing criteria
that establish the appearance of a youthful neck (Figure
1). An illustration of the neck of a 26-year-old model was
used to demonstrate the criteria. The authors described
extensive radical defatting of the subplatysmal plane,
along with full width transection of platysma muscle
flaps to accomplish this “youthful neck.” These criteria
are still used by the advocates of subplatysmal surgery to
contour the neck (Figure 2).
During the late 1970s and early 1980s, virtually all
face lift panels and courses were recommending this
approach to the neck.23-25 As a young plastic surgeon
just out of residency, I espoused these techniques as the
only method to obtain the best result. Whenever I performed this operation and observed the dramatic transformation of the neck on the operating table, I felt heroic. However, 6 months postoperatively, when my
patients developed submental hollowing and neck irregularities, I regretted having been so aggressive. It was
only after many years of patient complaints, complications, and overoperated necks that most plastic surgeons
abandoned these techniques.
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(1980)
Figure 1. Criteria for a youthful neck.22 (Redrawn after Ellenbogen and Karlin) 1980.
A
B
Figure 2. A, This 24-year-old woman has the ideal “youthful” neck. To attempt to create this neck in all patients is unrealistic and poor aesthetic
judgment. B, During the 1980s, after undergoing neck contouring with complete platysma transection and flaps, patients would frequently complain of
feeling as if a baby bonnet were tied under their chin and neck.
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B
A
Figure 3. A, Preoperative view of a 55-year-old woman. B, Postoperative view 1 year after excision of subplatysmal fat.
I finally realized that to attempt to create the neck of a
26-year-old model in all patients was both unrealistic and
poor aesthetic judgment. I understood that it was a mistake to treat anatomical defects as isolated characteristics. A good face lift and necklift demonstrate a sense of
balance and proportion in accordance with the physiognomy and aesthetics of each patient. A woman with a full
face and short neck would look unnatural with the neck
of a 110-lb 26-year-old model. As we age, softer contours and more fullness are more appropriate and pleasing. As one very experienced surgeon so aptly stated,
“We must be extremely careful and conservative in order
to avoid overcorrecting and deforming the neck with an
abnormally sharp cervicomental angle.”26-28 The aesthetic
criteria of the 1980s need modification.
Subplatysmal Fat
I am still occasionally motivated to conservatively
resect subplatysmal fat in certain patients, but months
later, when the edema subsides, I usually regret it (Figure
3). An outstanding paper on fat contouring of the face
and neck was published in 1992.29 Following are some of
the important concepts that Lambros advocates and I still
adhere to:
1. The contoured neck should be left undercorrected at
the conclusion of the procedure.
2. The surgeon must leave a precise amount of fat that
will produce an attractive neck 6 months or more
after wound maturation.
Face Lift With Submandibular Gland and Digastric
Muscle Resection: Radical Neck Rhytidectomy
AESTHETIC
3.
The goal of neck contouring surgery should be a
youthful or, at least, a graceful-looking neck,
attractive by virtue of its simplicity rather then by
its complexity.
4. Beware of the tendency to overexcise subplatysmal fat
and turn the surgery into a “fat frenzy” (Figure 4).
5. Exposing the mylohyoid never looks good over the
long term, ultimately resulting in hollowing between
the digastrics.
In a round, full face with a thick, short neck, I generally prefer the aesthetic result when I do not remove fat
beneath the platysma muscle.
Digastric Muscle
The paired digastric muscles help raise the hyoid bone
during speech and swallowing and facilitate opening of
the mouth. I have never agreed with the concept of
resecting a “hypertrophic” anterior belly of the digastric
muscle to contour the neck. (In fact, I always wondered
how that muscle becomes “hypertrophic.”) I also do not
agree with evaluating submental fullness by having the
patient gaze downward as he or she might do while eating or reading.3,6,7,19 That particular view has never been
relevant when I evaluate the aesthetics of patients’ necks.
(In the cadaver lab, flexing the neck forced the anterior
bellies of digastric muscle to “bunch up” and protrude
below the mandibular border, which I consider normal.) I
prefer to evaluate the neck, both on the operating table
and postoperatively, while it is in the neutral position.
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A
B
Figure 4. A, Preoperative view of a 66-year-old woman. B, Postoperative view 1 year after radical defatting with full-width platysma transection and
flaps.
Some surgeons like to flex the neck after removing
subcutaneous and subplatysmal fat, and if there are
bulges from the digastric muscle, the surgeon may then
resect as much as 90%.6,7 The goal is to accomplish a
“slightly concave”9 submental area on the operating
table, creating a “…concavity to define the jawline and
chin-neck concavity.”8 To date, none of the surgeons has
ever reported a complication. One surgeon, however,
takes an opposite view and does not resect digastric muscle because he feels it leads to a weakening of the floor of
the mouth and subsequent herniation of the contents of
the floor of mouth.30
My experience in dissecting a male cadaver with a
thick, full neck is that it looked pleasing after subcutaneous fat removal. However, when subplatysmal fat was
removed down to mylohyloid and the neck was flexed, the
digastric muscles bulged and the submandibular glands
were pushed below the mandibular border. Resecting
90% of the anterior belly of digastric muscles resulted in
an excessively concave submental area (Figure 5). My
concerns about routinely resecting this muscle are submental depressions, interference with swallowing, and
allowing the submandibular gland to become more prominent. In summary, I believe the digastric muscle rarely, if
ever, contributes to a significant submental fullness in the
unflexed neck. My preference is to leave the muscle
untouched and maintain fuller, softer submental contours.
Submandibular Gland
The submandibular glands secrete 45% of the salivary fluid. Saliva is important for lubrication of food,
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protection of the teeth, and also has antibacterial activity containing secretory immunoglobulin A and
lysozyme. As we age, the flow rate of saliva decreases. It
is also affected by many common medications. 31
Anyone who has treated head and neck cancer patients
after radiation knows the severe debilitation caused by
dry mouth.
The first report of submandibular gland resection in
face lifting was in 1991 when 12 partial resections of the
superficial lobe were performed in 8 women.32 The preferred approach was via the face lift incision, and no complications were reported. In 2003, Singer20 described a
submental approach to gland resection utilizing 15 digastric triangle dissections in fixed and fresh cadavers. The
descriptions and anatomical study are excellent. What is
disturbing is the “Discussion” section of this paper33 in
which the “safety and efficacy” of this technique are mentioned no less then 3 times. This discussion is a commentary on a paper that is confined to cadaver dissections;
there are no clinical cases. In fact, the 8 patients in 1991
comprised the only series of submandibular gland resections in face lift procedures reported in the literature.32
Most other reports of submandibular gland resections are
more anecdotal, included when the surgeon discusses neck
contouring.8,9,11,13,15,16,19
Most surgeons feel that the primary risk in submandibular gland resection is injury to the marginal
mandibular nerve.20 This, however, is not my greatest
concern.34 Consider that the vascular supply to the
gland is variant, significant and abundant, and that the
submental approach requires the surgeon to operate in a
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Figure 5. Postoperative view of a 51-year-old woman 1 year after resection of subplatysmal fat and subtotal resection of digastric muscles.
hole (Figure 6).20 Significant postoperative hemorrhage
from the remaining gland could occur beneath the deep
cervical fascia, and a rapidly expanding hematoma
could compromise the patient’s airway. The worst scenario would be an emergency tracheostomy and a long
submandibular incision to control bleeding. With distorted, edematous hemorrhagic tissues, vital nerves and
structures could easily be damaged on re-exploration.
One surgeon who apparently has had extensive experience with submandibular gland resection states that he
“…used to do many partial resections but because large
arterial vessels run through the gland and are difficult
to control, this procedure can be hazardous. An irregular appearance may also result from partial resection.”12 He now recommends removing the entire
superficial lobe, and the procedure takes him about 1
hour for each side.
I would encourage surgeons to be cautious in
asserting that this is a safe technique until some large
series are reported and a standard technique has been
proven effective.
Some of the unanswered and controversial questions are:
• How much gland needs to be resected?
• Should the capsule be closed?
• Are drains necessary? Where should they be
placed?
• What approach should be used for expanding
neck hematoma?
Over the years, I have certainly had some patients
complain about prominent submandibular glands after
Face Lift With Submandibular Gland and Digastric
Muscle Resection: Radical Neck Rhytidectomy
AESTHETIC
undergoing face lift surgery. And I did think there would
be aesthetic improvement if the glands were removed.
Overall, I am quite satisfied with the suspension and
tightening provided by suturing the platysma.35 However,
I have learned to examine the glands and discuss their
anatomy with the patient during the preoperative evaluation. I also have patients feel their own glands while I
explain that these glands may become more prominent
postoperatively when fat is contoured and skin is tightened. I then discuss the possibility of gland removal,
explaining that these are normal glands that secrete 45%
of the mouth’s saliva. When I begin to discuss the potential risks and complications, I rarely get through half the
list before the patient interrupts and says: “That’s okay,
Doc, I want to leave them.”
In performing fresh cadaver dissection, after removing
subplatysmal fat down to the mylohyoid and resecting
90% of the anterior digastric muscles and both superficial
lobes of the submandibular gland, I reapproximated the
medial platysma borders and closed the skin. On inspection, I had truly created a cadavaric neck (Figure 7).
Informed Consent, Standard of Care
At present, I do not consider resecting submandibular
glands to be the standard of care in recontouring necks.
Following is a summary of essential elements that should
be included in any discussion of gland removal:
Advantage of submandibular gland removal
1. Neck contour presumed better
Disadvantages of submandibular gland removal
1. Time consuming (1 hour per side)
2. Limited exposure (operate in a hole)
3. Recurrence as a result of inadequate resection
4. Prolonged submental edema and induration
5. Potential major complications
Potential complications of submandibular gland resection
1. Dry mouth (submandibular gland produces 45%
saliva, which decreases with age)
2. Salivary fistula
3. Sialoma
4. Nerve injury VII, XII, lingual
5. Neck irregularities and depressions
6. Cadavaric neck
7. Hemorrhage ➝ Expanding Hematoma ➝
Compromised Airway ➝ Tracheostomy
8. Unplanned neck incision to control bleeding
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A
B
C
D
Figure 6. A, Fresh male cadaver with full, thick neck; submandibular glands outlined. B, Cervical flaps elevated to expose platysma. C, Subplatysma
exposure of submandibular gland. D, Superficial lobe of submandibular gland dissected to expose complex neurovascular structures.
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A
Figure 7. A, Cadaver neck following resection of subplatysmal fat, partial resection (90%) of digastric muscles, and excision of superficial lobes
of submandibular glands. (All preplatysmal fat was left on the flaps.) Platysma has been reapproximated in midline beneath the skin flap.
B, Postoperative view of a 69-year-old woman 1 year after “radical neck cleanout” (subplatysmal fat, digastrics, submandibular glands).
Unfortunately, much of one’s surgical judgment
evolves from experiencing complications, poor results,
and doing revisions. What works well for one surgeon
may be catastrophic for another. My favorite advice to
residents has always been, “The most important decisions
you make in surgery are what you decide not to do.”
Conclusion – Summary
Although the debate continues about which rhytidectomy technique yields the best results, there is no single
technique that is “best.” Most techniques are variations
on a basic theme. What has clearly evolved in the 21st
century is the trend to less invasive procedures with low
morbidity, short recovery, and minimal scars. That most
patients are happy with the simpler techniques is obvious. And the fact that the deeply invasive, more radical
techniques do not produce appreciably better results36
has motivated most plastic surgeons around the world to
rely on the less complicated standard techniques.
I realize that I have been very critical of the subplatysmal approach resecting fat, muscle, and salivary glands.
However, at present, I believe my criticisms are valid. To
date, this approach has no reported large series of cases,
no standardized evaluation or surgical technique, and no
reported complications. I know all surgery has complications. I suffer enough stress with the complications I have
to treat now. Why would I want to deal with more?
Face Lift With Submandibular Gland and Digastric
Muscle Resection: Radical Neck Rhytidectomy
AESTHETIC
The surgeons performing and advocating these operations are among the very best. They show some good
results. They are bold and creative, and I applaud their
curiosity and innovation. I am glad we have them as pioneers, and hopefully, I will benefit from their techniques
if proven safe and effective. Until then, it is a surgical
approach I have decided not to use. ■
References
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