Options for Neck Sculpting with or without Submandibular Gland Removal
Excess fat and sagging neck skin are a common frustration amongst patients as they age. Age related changes result in cervicomental angle widening secondary to increased fat production, skin laxity, and submandibular gland hyperplasia. The platysmaplasty tightens and contours the neck to address the obtuse cervicomental angle caused by aging. However, the submandibular gland may project beyond the mandible and results in a cobra neck deformity if it is not addressed. Because gland hyperplasia is common in the aging process, it is important to evaluate the size of the glands in order to determine their contribution to the obtuse neck. Despite publications proving that removal/partial removal of the submandibular glands provides improved aesthetic outcomes, surgeons avoid the deep neck structures because of the perceived increased risk of uncontrolled bleeding or nerve injury. In addition, some patients, despite the clear indications for jawline aesthetics, elect to not have the gland excised for fear of xerostomia. We offer an option for improving jawline aesthetics without removal of the gland. The hyoid periosteum to mastoid crevasse sling can be used to elevate the submandibular gland behind the mandible. This technique can also be employed when removing the gland to further accentuate a sharp cervicomental angle.
Methods/Technique
:The neck lift with submandibular or partial submandibular gland excision is performed by the senior author in the following fashion: the central neck is opened with a submental incision. The preplatysmal fat is excised and the platysma is lifted off of the strap muscles. The subplatysmal fat is also removed. The submandibular capsule is opened, and the excess gland is excised to the level of the mandible with bipolar cautery. The capsule is repaired and the platysmaplasty is performed with 3-0 PDS. Next a 3-0 PDS is placed through the platysma muscle directly over the submandibular gland. It is then brought medially and placed through the hyoid periosteum. Then under direct vision the platysma muscle is lifted so the exact location of the submandibular gland can be identified. It is at this point that the 3-0 PDS then again passed through the platysma muscle to the anterior surface of the muscle. The suture is then delivered into the posterior neck where it is placed over the mastoid bone within a crevasse created by incising the fascia directly over the mastoid bone. This is done bilaterally and with the tightening of these sutures the submandibular glands are suspended above the border of the mandible.
Results/Complications
:There were no major bleeding complications intraoperatively or postoperative hematomas. There were no reported cases of nerve injury, sialoceles, or xerostomia. All patients who underwent the procedure endorsed improved aesthetic outcomes and a notable decrease in cervicomental angle.
Conclusion
:The mechanics of an aesthetically crafted neck and jawline mandate treatment of the deep neck structures, which include the submandibular gland. In scenarios where, either the surgeon is uncomfortable removing the gland or the patient requests their gland not be disturbed, a conundrum exists for the surgeon. We propose the hyoid periosteum to mastoid crevasse sling as a solution to achieve not only a sharp cervicomental angle but also a well-defined gonial angle which can be observed optimally by the reverse ogee view.