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Facial Surgery

Commentary

Commentary on: Characterization of the Cervical Retaining Ligaments During Subplatysmal Facelift Dissection and its Implications

Aesthetic Surgery Journal

2017, Vol 37(5) 502–503

© 2017 The American Society for

Aesthetic Plastic Surgery, Inc.

Reprints and permission:

journals.permissions@oup.com

DOI: 10.1093/asj/sjx043

www.aestheticsurgeryjournal.com

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James E. Zins, MD, FACS; and Gehaan F. D’Souza, MD

Editorial Decision date: February 14, 2017

A basic tenet of facial aging surgery is as follows: ligamentous release allows for the mobilization of skin and soft tissue distal to this attachment. This is true in brow elevation, in the correction of the tear trough deformity which requires release of the orbicularis retaining ligament, and in the midface, which requires release of the major zygomatic cutaneous ligament to mobilize the distal soft tissues. This is also pointed out by the current authors who advocate posterior platysma mobilization by releasing the cervical retaining ligaments.Jacono et al1 convincingly argue that this release of the cervical retaining ligaments should provide an enhanced result when compared to the platysma window technique as described by Cruz et al.2 According to the Cruz et al’s description of their procedure they fail to release the cervical retaining ligamentous attachments. Cervical retaining ligament release as described by Jacono et al may also improve the MCACS lift results since minimally access cranial suspension (MACs) lifting obtain its benefits to neck contouring through a posterior and vertical shortening of the superficial muscular aponeurotic system (SMAS) and platysma complex without ligamentous release. However, the benefit of the current technique over submental midline platysmaplasty is less clear.

A second basic principle of facial aging surgery is that laxity is best treated where laxity is greatest. Consider the
eyebrow. The most effective means of brow elevation mechanically is through a direct brow lift. We do not perform this maneuver on a consistent basis because of the visible scar. From a mechanical standpoint, however, this is the most effective approach. Similarly, platysmal laxity is greatest medially as evidenced by platysma banding and therefore is best addressed medially. Further, if the submental approach is foregone, the option for surgical defatting under direct vision, subplatysmal defatting, digastric muscle alteration, and/or submandibular gland partial removal is bypassed.

Jacono et al critique Feldman’s corset platysmaplasty suggesting that redundant platysma is pulled into the submental region potentially adding bulk and introducing submental irregularities.3 However, when the corset is properly executed which includes contouring of the intermediate plane, including subplatysmal and occasionally digastric muscle removal, space is created to imbricate redundant muscle. When properly performed, a beautiful neck is the result.

Jacono et al also critique the midline platysmaplasty for creating a downward trajectory that opposes the forces applied to the lateral facelift flap. I would beg to differ. When performing an extended SMAS as suggested by Stuzin the SMAS should be done first. This not only tightens the SMAS but because of the continuity of the SMAS and platysma and the minimal boney contact, this tightens the platysma and passively repositions the lower face and neck fat into the face (Dr J. Stuzin, personal communication). Then

From the Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio. Dr Zins is Facial Surgery Section Editor for Aesthetic Surgery Journal.

Corresponding Author:

Dr James E Zins, Chair, Department of Plastic Surgery, Cleveland
Clinic, 9500 Euclid Avenue, Suite A-60, Cleveland, OH 44195, USA.
E-mail: zinsj@ccf.org

The marginal mandibular nerve passes from deep to the masseteric fascia to the sub-SMAS position at the level of the facial vessels

Figure 1. The marginal mandibular nerve passes from deep to the masseteric fascia to the sub-SMAS position at the level of the facial vessels. This is where it is most likely to be injured (reprinted with permission from Oxford University Press9).

the platysmaplasty merely takes up the remaining laxity. In addition, if wide undermining of face and neck skin is performed without addressing the SMAS as advocated by Feldman and Hoefflin, this becomes a moot point.4,5

With regard to Jacono et al’s description of the deep posterior platysma attachments as cervical retaining ligaments, this is semantics. Are these structures true ligaments as defined by Stuzin going from bone to skin?6 Or are these areas of fusion of superficial or deep fascia? I would favor the later. Finally, for completeness sake, histologic identification of the areas of soft tissue fusion should be obtained.

A point of clarification: while Jacono et al refer to Hamra and his deep plane technique, what they are describing with their approach more closely resembles Skoog’s original procedure which was a sub-SMAS and subplatysmal approach.7 Hamra, incidentally whose first major contribution was his paper describing 577 Skoog’s facelifts, realized the shortcomings of that technique.8 That is, the skin tended to be more lax than the platysma leading to early recurrence of skin excess in the neck. He therefore changed planes in the neck from a subplatysmal plane to a subcutaneous plane.

With regard to the marginal mandibular nerve, Jacono et al correctly state that the nerve is deep to the masseteric fascia
as it exits the parotid. However, the nerve passes from deep fascia to a sub-SMAS location at the level of the facial vessels
just lateral and superficial to them. This is the location of the sub-SMAS “danger zone” which we described (Figure 1).9 It is not at the more medial level of the mandibular ligament. Since Jacono et al extend their dissection to this level the reader should be apprised of the need for care in this area.

And so the long standing controversy regarding neck aging will continue. There are those who prefer adding the anterior approach to their facelift. This includes Stuzin, Hamra, Feldman, Little, Nahai, and myself, among others. According to these authors, although there may be some minor additional added risk, it is worth the added benefits in most patients. There are those who prefer the posterior approach including Fogli, Tonnard, and the current authors.10 In spite of the insightful paper by Jacono et al, this is bound to go on.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this
article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

REFERENCES

  • Jacono AA, Malone MH. Characterization of the cervical retaining ligaments during subplatysmal facelift dissection and its implications. Aesthet Surg J.2017;37(5):495-501.
  • Cruz RS, O’Reilly EB, Rohrich RJ. The platysma window:an anatomically safe, efficient, and easily reproducible approach to neck contour in the face lift. Plast Reconstr Surg. 2012;129(5):1169-1172.
  • Feldman J. Neck Lift. St. Louis: Quality Medical Publishing, Inc; 2006:107.
  • Feldman JJ. Neck lift my way: an update. Plast Reconstr Surg. 2014;134(6):1173-1183.
  • Hoefflin SM. The extended supraplatysmal plane (ESP) face lift. Plast Reconstr Surg. 1998;101(2):494-503.
  • Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg. 1992;89(3):441-449;discussion 450.
  • Skoog T. Plastic Surgery: New Methods. Philadelphia:Saunders, 1974.
  • Hamra ST. Composite rhytidectomy. Plast Reconstr Surg.1992;90(1):1-13.
  • Huettner F, Rueda S, Ozturk CN, et al. The relationship of the marginal mandibular nerve to the mandibular osseocutaneous
    ligament and lesser ligaments of the lower face. Aesthet Surg J. 2015;35(2):111-120.
  • Fogli A, Desouches C. Less invasive face-lifting: platysma anchoring techniques. Clin Plast Surg. 2008;35(4):519-529, vi.

REFEREED ORIGINAL ARTICLES :

  • D’Souza GF, Zins JZ. Exophytic Plantar Wart Treatment in an Immunocompromised Patient. New England Journal of Medicine. Accepted.
  • D’Souza, GF, Zins JZ. Facial Plastic and Reconstructive Surgery: Clinical Reference Guide. Annals of Plastic Surgery. Accepted
  • De La Poazza E, D’Souza GF, Zins JZ. Patient Satisfaction with an Early Smartphone-Based Cosmetic Surgery Postoperative Follow-up. Aesthetic Surgery Journal. Accepted.
  • Richards B, D’Souza GF, Zins JZ. The Role of Injectables in Aesthetic Surgery: Financial Implications. Aesthetic Surgery Journal. Accepted.
  • D’Souza, GF, Zins JZ. Commentary on: Characterization of the Cervical Retaining Ligaments during Subplatysmal Facelift Dissection and its Implications. Aesthetic Surgery Journal. Aesthet Surg J. 2017 May 1;37(5):502-503.
  • D’Souza GF, Zins JZ. Skin Only Facelift. Operative Techniques in Plastic Surgery. Submitted
  • D’Souza GF, Zins JZ. Phenol Peel. Operative Techniques in Plastic Surgery. Submitted
  • D’Souza GF, Brandel, MB, Zins JZ. The Skin Only Facelift. Plastic Surgery: Clinics in Surgery. Submitted
  • Hashem A, Waltzman J, D’Souza GF, Kenkel J, Zins JZ. Resident and Program Director Perceptions of Aesthetic Training in Plastic Surgery Residency: An Update. Aesthetic Surgery Journal. 2017 Mar 3.
  • D’Souza GF, Bernard S. The Role of Pizoelectric Instrumentation in Rhinoplasty Surgery. Book Review. Plastic Surgery Education Network. Website Publication.
  • D’Souza, GF, Zins JZ. Anatomy for Plastic Surgery of the Face, Head, and Neck. Book Review. Plastic Reconstructive Surg. DOI: 10.1097/PRS.0000000000003034
  • D’Souza GF, Brown, J. 100 Case Reviews in Neurosurgery. Median Nerve Injury.
  • D’Souza GF, Brown, J. 100 Case Reviews in Neurosurgery. Radial Nerve Injury.
  • D’Souza GF, Gosman A. Evaluation of an Academic Resident Aesthetic Clinic from Perspective of Patient and Resident. Plastic Reconstructive Surg. 2015 Oct; 136 (4 Suppl):122-3.
  • D’Souza GF, Qiu F, Ly Q. Tumor Characteristics Influence the Reconstructive Surgical Decision Making of Breast Carcinoma Patients. Journal of Surgical Oncology. Submitted for Publication.
  • Tenenhaus M, D’Souza GF. Wound Healing Biomaterials: Therapies and Regeneration. Journal Lower Extremity Wounds. 2014 Dec; 13 (4):335-46
  • D’Souza GF, Abdessalam S. Volvulus of the Appendix: A Case Report. Journal of Pediatric Surgery. 46:8 e63, 2011.
  • D’Souza GF, Evans GR. Mexoryl: A Review of an Ultraviolet A Filter. Plastic and Reconstructive Surgery. Plastic Reconstructive Surg. 2007 Sep 15; 120(4):1071-5.
  • D’Souza GF, Milliken JC. Patent Ductus Arteriorus. E-medicine. Cardiology, Website Publication. (2007, February 17).
  • D’Souza GF, Milliken JC. Ventricular Septal Defect. E-medicine. Cardiology, Website Publication. (2007, February 17).
  • WenLian X, Dunn CA, Jones CR, D’Souza GF, Bessman MJ. The 26 Nudix Hydrolases of Bacillus Cereus: A Close Relative of Bacillus Anthracis. Journal of Biological Chemistry. 2004 Jun 4; 279(23):24861-5

ABSTRACTS

  • D’Souza GF, Reid C, Gosman A. The Process for Rhinoplasty in a Resident Aesthetic Clinic: Optimizing Outcomes and Satisfaction. California Society Plastic Surgery Meeting. Publication. 2016.
  • D’Souza GF, Gosman A. Evaluation of an Academic Resident Aesthetic Clinic from Perspective of Patient and Resident. UCSD Department of Surgery Research Symposium Publication. 2015.
  • D’Souza GF, Baker J, Mailey M, Hosseini A, Wallace A. Acellular Dermal Matrix Increases Complications in Breast Reconstructive Patients. Annals of Plastic Surgery. 2014.
  • D’Souza GF, Qiu F, Ly Q. Tumor Characteristics Influence the Reconstructive Surgical Decision Making of Breast Carcinoma Patients. Journal of Surgical Research. 41:138-139. 2011.
  • D’Souza GF, Qiu F, Ly Q. Influence of Tumor Characteristics in the Surgical Decision Making of Breast Cancer Patients. Journal of Women’s Health. 42:310. 2011.
  • D’Souza GF, Evans GR, Dhar S. Gankyrin in Breast Cancer Biology. Journal of Investigative Medicine. Volume 55:52, 2007.
  • D’Souza GF, Evans GR, Dhar S. Significance of Gankyrin in Breast Cancer Biology. Transactions of the Plastic Surgery Research Council. 51(1): 183, 2006.

PRESENTATIONS/POSTER SESSIONS

  • D’Souza GF, Zins JE. Anterior Neck Lift. Poster Presentation: Ohio Valley Plastic Surgery Society. 2017.
  • D’Souza GF (2016 June). The History of the Rhytidectomy.
  • D’Souza GF, Reid C, Gosman A. The Process for Rhinoplasty in a Resident Aesthetic Clinic: Optimizing Outcomes and Satisfacation. California Society Plastic Surgery Meeting. Publication. 2016.
  • D’Souza GF, Qiu F, Ly Q (2016 May). Tumor Characteristics Influence the Reconstructive Surgical Decision Making of Breast Carcinoma Patients. Academic Surgical Congress.
    1. Oral Presentation: Academic Surgical Congress. Jacksonville, FL.
  • D’Souza GF, Gosman A (2015 October). Evaluation of an Academic Resident Aesthetic Clinic from Perspective of Patient and Resident. UCSD Department of Surgery Research Symposium.
    1. Oral Presentation: American Society of Plastic Surgery. Boston, MA.
  • D’Souza GF (2015 June). Orthognathic Surgery of the Mandible.
    1. Oral Presentation: University of California, San Diego, Plastic Surgery, Grand Rounds. San Diego, CA.
  • D’Souza, GF (2015 March) Facial Aesthetic Analysis.
    1. Oral Presentation: University of California, San Diego, Plastic Surgery, Grand Rounds. San Diego, CA.
  • D’Souza, GF (2014 July) Facial Reconstruction.
    1. Oral Presentation: University of California, San Diego, Plastic Surgery, Grand Rounds. San Diego, CA.
  • D’Souza GF (2014 July) Flaps and Grafts.
    1. Oral Presentation: University of California, San Diego, Plastic Surgery, Grand Rounds. San Diego, CA.
  • D’Souza GF (2014 August) Microsurgery.
    1. Oral Presentation: University of California, San Diego, Plastic Surgery, Grand Rounds. San Diego, CA.
  • D’Souza GF (2014 August) Flaps of the Lower Extremity.
    1. Oral Presentation: University of California, San Diego, Plastic Surgery, Grand Rounds. San Diego, CA.
  • D’Souza GF (2014 July) Non-Surgical Facial Rejuvenation.
    1. Oral Presentation: University of California, San Diego, Plastic Surgery, Grand Rounds. San Diego, CA.
  • D’Souza GF (2014 September) Breast Cancer – New Frontiers.
    1. Oral Presentation: University of California, San Diego, Plastic Surgery, Grand Rounds. San Diego, CA.
  • D’Souza GF (2014 April) Lower Extremity Reconstruction.
    1. Oral Presentation: University of California, San Diego, Plastic Surgery, Grand Rounds. San Diego, CA.
  • D’Souza GF, Baker, J, Mailey, M, Hosseini, A, Wallace A (2014 May) Acellular Dermal Matrix Increases Complications in Breast Reconstructive Patients.
    1. Oral Presentation: California Society of Plastic Surgery. Newport Beach, CA.
  • D’Souza GF, Qiu F, Ly Q. (2011, April) Influence of Tumor Characteristics in the Surgical Decision Making of Breast Cancer Patients.
    1. Oral Presentation: Women’s Health Congress. Washington, DC.
  • D’Souza GF (2012, October). Breast Cancer Trends,
    1. Oral Presentation: University of Nebraska, General Surgery Grand Rounds; Omaha, NE.
  • D’Souza GF (2012, November). Vascular Surgery Case Presentation,
    1. Oral Presentation: University of Nebraska, General Surgery Grand Rounds; Omaha, NE.
  • D’Souza GF (2007, October). The Jejunal Flap.
    1. Oral Presentation: University of California, Irvine, Plastic Surgery, Grand Rounds. Irvine, CA.
  • D’Souza GF, Evans GR, Dhar S (2006 May). Significance of Gankyrin in Breast Cancer Biology.
    1. Oral presentation: Plastic Surgery Research Council. Dana Point, CA.
  • D’Souza G, Evans GR, Dhar S. (2005 September). Tumor Suppressor Gene KLK10 in Breast Cancer Tissue Progression.
    1. Poster Presentation: California Tissue Engineering Meeting, Irvine, CA.
  • D’Souza G, Evans GR, Dhar S. (2005, November). Significance of Gankyrin in Breast Cancer Biology.
    1. Poster Presentation: American Medical Association; Dallas, TX.
  • D’Souza G. (2002, November). Mutant Parathyroid Receptor (Jensen’s Chronodoplaysia & Muscular Oleurism). Oral Presentation: Johns Hopkins University, School of Medicine, Department of Pediatric Endocrinology, Grand Rounds, Baltimore, MD.

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