B Teimourian

DM Knize

GP Maxwell

Hans-Peter Zweep

J Guerrerosantos

JC Grotting

JE Zins

JM Gryskiewicz

JM Kenkel

MK Gingrass

ML Zocchi

OM Ramirez

Patrick P. G. M. Rooijens

R Singer

RJ Rohrich

TA Miller

TD Cronin

TM Biggs Jr

VC Giampapa

Werner H. Beekman

English

PubMed

Crossref

Springer - Publisher Connector

ORIGINAL ARTICLE
Combined Use of Ultrasound-Assisted Liposuction
and Limited-Incision Platysmaplasty for Treatment
of the Aging Neck
Patrick P. G. M. Rooijens Æ Hans-Peter Zweep Æ
Werner H. Beekman
Received: 9 April 2008 / Accepted: 26 June 2008 / Published online: 25 July 2008
 The Author(s) 2008
Abstract
Background Many techniques have been introduced for
the surgical treatment of the aging neck. In this study the
combination therapy of ultrasound-assisted liposuction and
limited-incision platysmaplasty for cervicofacial rejuve-
nation is presented.
Methods Fifteen female patients (age = 43–75 years)
were treated for grade II–III (n = 2), III (n = 6), and grade
IV (n = 7) cervicomental angle deformity. The outcome of
surgery was retrospectively evaluated by a panel.
Results Ultrasonic energy was applied for an average of
2 min (range = 45 s–6.5 min). The mean aspiration vol-
ume was 125 ml. No immediate or delayed adjuvant skin
reduction was needed in any of the patients. No compli-
cations were encountered in this series. After treatment
significant improvement of the cervicomental angle was
observed.
Conclusion For treatment of all grades of the aging neck
we advocate the combination of UAL and limited-incision
platysmaplasty. This combination therapy has little mor-
bidity and leads uniformly to significant improvement of
the cervicomental angle.
Keywords Aging neck  Liposuction  Ultrasonic 
Platysmaplasy
Introduction
Many techniques have been introduced for the surgical
treatment of the aging neck [1–13]. Most techniques
involve a face-lift procedure. However, this procedure is
not necessary for every patient who presents with redun-
dancy of skin or accumulation of fat in the submental area
and adjacent neck. They may be satisfied with a less
invasive procedure, reducing downtime but still getting an
optimal result. Until now, there were no studies in the lit-
erature that described the combined use of ultrasound-
assisted liposuction (UAL) and limited-incision platys-
maplasty for the treatment of the aging neck. In this report
the combination therapy of UAL and platysmaplasty for
cervicofacial rejuvenation is presented in a retrospective
study of 15 selected patients.
Patients and Methods
Patients
Fifteen patients who sought neck rejuvenation were
included in this study. According to the classification
advocated by Knize (Fig. 1) [8], two patients were inclu-
ded with a grade II–III, a mild to moderate cervicomental
angle deformity; six patients with a grade III, moderate
cervicomental angle deformity; and seven patients with a
grade IV, severely oblique cervicomental angle (Table 1).
Surgical Technique
To prevent bias, all patients were treated by one surgeon.
The patients were operated on in day-care surgery. All
markings were made with the patient in an upright position.
P. P. G. M. Rooijens (&)
Department of Plastic and Reconstructive Surgery, VU Medical
Center, De Boelelaan 1117, 1007 MB Amsterdam,
The Netherlands
e-mail: p.rooijens@vumc.nl
H.-P. Zweep  W. H. Beekman
Department of Plastic and Reconstructive Surgery,
Tergooiziekenhuizen, location Hilversum, Van Riebeeckweg
212, 1213 XZ Hilversum, The Netherlands
123
Aesth Plast Surg (2008) 32:790–794
DOI 10.1007/s00266-008-9215-x
Concentric topography-type marks were centered on the
most prominent portion of the submental region. The
incision site just posterior to the submental crease was also
defined.
Patients were operated on under general anesthesia in
the supine position, with the neck extended on a surgical
headrest. Preoperatively 1 g of flucloxacillin (Glaxo-
SmithKline BV, Zeist, the Netherlands) was administered
intravenously during induction. A stab incision just pos-
terior to the submental crease was made to facilitate
tumescent infiltration with a solution of 1 l of 0.9% NaCl,
25 ml of 1% lidocaine, 1 ml of 1:100,000 epinephrine, and
12.5 ml of 8.4% sodium bicarbonate [14].
Liposuction was performed using an ultrasonic genera-
tor (Lysonix; Mentor Corporation, Santa Barbara, CA) with
an open-tip 3-mm cannula. This cannula was passed mul-
tiple times in a fanlike pattern to emulsify the fatty tissue.
Final evacuation of liquefied fatty tissue and contouring of
the neck was performed with a standard 3-mm cannula
(Tulip; Tulip Biomed, San Diego, CA).
Subsequently, the platysmaplasty was performed by
extending the stab incision up to 3 cm. The submental skin
was undermined to the level of the cricoid cartilage and
raised with a retractor. The medial platysma muscle edges
were identified and raised and the subplatysmal plane was
inspected for excess fat depositions. If present, the sub-
platysmal fat was resected. Finally, the medial platysma
muscle edges were approximated in the midline using
mattress or figure-of-eight plicating sutures of Vicryl 3–0
(Ethicon GmbH, Johnson & Johnson, Hamburg, Germany).
After secure hemostasis, the wound was closed in layers
with interrupted subcutaneous Vicryl 4–0 and a continuous
intracutaneous Monocryl 5–0 (Ethicon GmbH, Johnson &
Johnson) suture. A chin strap was worn continuously for
10 days.
Cosmetic Assessment
Standardized photographs were taken by a professional
medical photographer preoperatively and 6 months post-
operatively. These photographs were graded by a panel
according to the classification of Knize (Fig. 1) [8]. The
panel consisted of three plastic surgeons and two plastic
surgery residents. Two slides were used for this evaluation:
the frontal view of the patient and the left profile.
Results
The described technique was used for 15 patients (all
female) with a mean age of 57 years (range = 43–
75 years). Ultrasonic energy was applied for an average of
2 min (range = 45 s–6.5 min). The mean aspiration vol-
ume was 125 ml (range = 25–200 ml). No hematoma,
seroma, infection, skin necrosis, contour irregularity, or
other complications were encountered in this series. The
preoperative status (degree of obliquity of the cervico-
mental angle) and the postoperative results at 6 months, as
graded by the panel, are given in Table 1. After treatment
significant improvement of the cervicomental angle was
observed (Figs. 2–5).
Discussion
In our opinion too often a total face-lift procedure is
performed to correct the submental laxity. As a result,
the deformity is corrected but often visible periauricular
scarring may not be avoided. To prevent this, many
other techniques have been described. One technique
involves cervicoplasty without skin excision, predomi-
nantly performed without skin excision [3, 6, 7, 10].
Other techniques involve excision of redundant neck
skin and fat with platysma plication and Z-plasty
closure of the skin [1, 2, 9], or a platysmaplasty with or
without suction-assisted lipectomy of the submental area
[5, 8, 11, 12]. Only one article favors a technique of
cervicofacial rejuvenation that involves UAL as a single
procedure [4].
UAL has several advantages over conventional lipo-
suction. Using UAL, fat is more selectively emulsified,
Fig. 1 Classification of cosmetic deformity of the neck. Grade I:
normal cervicomental angle; grade II: mild; grade III: moderate;
grade IV: severely oblique cervicomental angle [8]
Table 1 Degree of cervicomental angle deformity preoperatively,
number of patients treated, and postoperative grade
Preoperative
grade
Number of
patients
Postoperative
grade
Number of
patients
II–III 2 I 1
I–II 1
III 6 I–II 2
II 4
IV 7 II 2
II–III 1
III 4
Aesth Plast Surg (2008) 32:790–794 791
123
leaving the higher-density fibroconnective tissues rela-
tively undamaged [15–17]. Moreover, UAL performed in
the appropriate subdermal plane allows for skin con-
traction in the postoperative healing period, abolishing
the need for adjuvant skin resection [18–20]. Our
experience confirmed that UAL could prevent skin
excision as a result of considerable skin contraction
(Figs. 2–4), even in older patients (Fig. 5). We advocate
limiting the application of ultrasound to a few minutes;
in this period the rate of emulsification is greater than
Fig. 2 Preoperative (left) grade
III and postoperative (right)
grade I–II views of patient with
cervicomental angle deformity
Fig. 3 Preoperative (left) grade
III and postoperative (right)
grade I–II views of patient with
cervicomental angle deformity
792 Aesth Plast Surg (2008) 32:790–794
123
the rate of evacuation. Afterward, we evacuate the
residual liquefied tissue by conventional liposuction with
a 3-mm cannula. Limiting the period of ultrasound use
will help to prevent excessive postoperative seroma for-
mation [15, 21, 22].
In the present study we observed a significant
improvement in the cervicomental angle by using a com-
bination of UAL and limited-incision platysmaplasty. This
method produces good, predictable results and is safe.
However, patients must be carefully screened and the
Fig. 4 Preoperative (left) grade
II–III and postoperative (right)
grade I views of patient with
cervicomental angle deformity
Fig. 5 Skin contraction in a 73-
year-old patient. Preoperative
(left) grade IV and postoperative
(right) grade III views of patient
with cervicomental angle
deformity
Aesth Plast Surg (2008) 32:790–794 793
123
limitations of the procedure clearly spelled out. These
patients will obtain improvement in profile only, with no
improvement in the midface [13]. Also, many older
patients with submental fullness and moderate residual
submental skin tone can benefit from this approach
(Fig. 5). This procedure also eliminates unnecessary peri-
auricular scarring. This was also concluded by Knize [8],
who performed limited-incision submental lipectomy using
conventional liposuction and platysmaplasty on 56
patients.
Conclusion
For treatment of all grades of the aging neck we advocate
the combination of UAL and limited-incision platysmapl-
asty. This combination therapy has little morbidity and
leads uniformly to significant improvement of the cervi-
comental angle.
Open Access This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
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