The Best (bolster equalization suture technique): Optimizing Skin Re-Draping in a Necklift
Skin laxity at the neck is often a primary concern of patients who present for facial/neck rejuvenation surgery consultation. Despite standard undermining, re-draping, and excising excess skin of the neck with a necklift, central neck skin laxity often persists post-operatively. In many cases, postoperative dressings and garments will advance undermined neck skin centrally and shift skin flaps forward over the platysma creating submental skin laxity. Overtightening of the neck skin can cause tension at the closure site and result in wound healing problems and flap necrosis. Techniques such as external quilting sutures have been described to reduce hematoma risk and internal quilting sutures (i.e. progressive tension sutures) have been described to more evenly re-drape skin and distribute tension across the flap. However, inconveniences and potential risks exist with both external and internal quilting sutures, including the risk of flap ischemia, nerve entrapment, hypopigmentation or hyperpigmentation, temporary dimpling, and added operative time.
In order to optimize skin re-draping after necklift while avoiding the aforementioned inconveniences and potential risks, the bolster equalization suture technique (BEST) was developed. The purpose of this study is to assess the safety of the BEST addition to a necklift, as well as the efficacy at eliminating residual central neck skin laxity.
Methods/Technique
:This is a prospective cohort study of patients of the senior surgeon who will undergo necklift with the BEST addition. A total of 30 patients will be included. All patients will undergo subcutaneous facelift with SMAS flap elevation and plastysmal plication/anterior digastric myotomy, as is customary for the senior surgeon. In addition, three separate external quilting sutures will be placed over protective bolsters, so as to protect the skin from the suture causing focal pressure. One bolster suture will be placed at the subhyoid depression along midline, after smoothing any residual skin laxity. Laterally, the neck skin will be re-draped in a superolateral direction while supine to accentuate the cervicomandibular groove. Then, below the angle of the mandible on each side, another bolster suture will be placed to maintain the position of the re-draped neck skin.
Patients will have the bolster sutures removed on post-operative day 5. Any complications such as skin necrosis, skin ischemia, dimpling, hypopigmentation, hyperpigmentation, and scarring will be documented. Photographs will be obtained 2-3 months after surgery and compared to pre-operative photographs. The cervicomental angle will be measured in pre-operative and post-operative photographs, and the degree of improvement of the cervicomental angle will be determined.
As a control, the last 30 patients who have previously undergone the same surgery by the senior surgeon but without the BEST addition will be selected. Their pre-operative and 2-3 month post-operative photographs will be obtained and degree of improvement of cervicomental angle measured. This will be compared to the degree of improvement noted in the necklift with BEST addition group.
For all 60 patients (30 with BEST addition, 30 without), the presence or absence of residual central neck skin laxity will be determined. Post-operative photographs for all patients will be reviewed by 2 plastic surgeons (not the senior surgeon) blinded to the type of surgery. Correlation of the BEST addition to necklift with absence of residual central neck skin laxity will be calculated.
Results/Complications
:In patients who underwent necklift with BEST addition, the cervicomental angle improved post-operatively. The degree of improvement was compared to the control group. The BEST addition to the necklift had a weakly positive correlation to a reduction of residual central neck skin laxity. Additionally, there were no cases of skin necrosis or skin ischemia with utilization of the bolster suture. There were no cases of dimpling, hypopigmentation, hyperpigmentation, or significant scarring post-operatively.
Conclusion
:The BEST addition to the necklift is a straightforward, efficient maneuver to equalize tension on the flap and improve skin re-draping. This reduces the risk of persistent central neck skin laxity which is often challenging to eliminate entirely with standard necklift techniques. The BEST addition to the necklift provides improved neck contour with no apparent increased risk of flap ischemia or necrosis, pigmentation changes, dimpling, or significant scarring.