Neck and platysmaplasty — What is almost always done and what almost never is
Why cervical liposuction is rarely the answer, what is done in the subplatysmal plane, medial and lateral platysmaplasty step by step, and the three manoeuvres that open the cervicomental angle.
Content intended for healthcare professionals. It does not replace clinical assessment and is not written as patient information.
Key points
- The commonest neck error is liposuctioning the wrong plane: in a non-obese patient most of the fat lies beneath the platysma, not above it.
- Cervical subcutaneous tissue gives a youthful look: emptying it does not slim the neck, it ages it and produces retractions.
- Three manoeuvres open the cervicomental angle and are performed almost always: digastric myotomy, prehyoid fasciotomy and partial band transection.
- Remove interplatysmal fat, not interdigastric fat: taking the latter fuses skin to the digastrics and produces the cobra neck.
- A natural neck has more central than lateral volume. Chasing absolute concavity is what betrays the surgery.
Almost never and almost always
| Manoeuvre | Criterion | Why |
|---|---|---|
| Cervical liposuction | Almost never | The fat is mostly subplatysmal. Emptying the superficial plane exaggerates the bands, produces retractions and does not achieve the result. Only if the pinched fold exceeds 3 cm and what is held is skin with subcutaneous fat |
| Platysmectomy | Almost never | If the cause is dynamic it is corrected by muscular transection; if adynamic, by a medial corset suture. Resecting muscle only creates unwanted tension. Only if the bands are very lax |
| Aggressive central lipectomy | Almost never | It fuses skin to the digastrics and produces the cobra deformity: a central depression flanked by two bulges |
| Digastric myotomy | Almost always | The anterior belly is usually hypertrophic or lax and causes submental bulging. The lax portion is resected |
| Prehyoid fasciotomy | Almost always | It frees the medial platysma from the hyoid and infrahyoid muscles, allowing more tension in the plication and opening the angle |
| Partial band transection | Almost always | Both the central band created by the platysmaplasty itself and the dynamic bands from hyperfunction. Always partial, never a complete division |
The rule that sums up the approach
Almost everything that needs doing in a neck lies beneath the platysma, and almost everything classically done lay above it. That change of plane is what separates an operated neck that looks natural from one that looks emptied. The clinic check is simple: pinch the submental tissue and ask the patient to swallow. If what stays between the fingers is skin with subcutaneous fat, there is superficial fat to treat; if it slips away on swallowing, the excess is deeper or is lax muscle, and liposuction will not reach it.
Medial platysmaplasty, step by step
- IncisionSubmental, about 2 cm, 2 mm caudal to the submental crease — it heals better there than on the crease — with a cold blade
- Supraplatysmal planeDissect to the sternocleidomastoid and the thyroid line, and run along the whole mandibular border releasing the mandibular ligament with scissors
- Opening the platysmaExactly in the midline, where there is usually no platysma. Beneath appear the digastrics, which mark the deep limit
- Subplatysmal planeDissect with vertical scissor movements until the glands are located, releasing the mandibular ligament from here as well
- FatLipectomy interplatysmal down to the digastrics, without ambition: interplatysmal fat is removed, not interdigastric fat
- Digastric and fasciaAnterior belly myotomy resecting the lax portion with bipolar, and transverse prehyoid fasciotomy of the deep cervical fascia — not the muscle — after palpating the hyoid with the finger
- GlandIf indicated, reduction of the external glandular portion, taking care not to injure the facial vessels — remembering that the vein lies anterior to the artery
- PlicationPlatysmal suture with 4/0 absorbable in cross stitches, submental and cervical. Do not use a running suture: it creates a visible central band
When to transect and how much
There are two different transections and each has its indication. The central prehyoid band is transected when, with the neck hyperextended, that band looks obtuse rather than sharp: it is the one the platysmaplasty itself creates. The dynamic band at the thyroid cartilage is transected when hyperdynamic bands were seen at assessment. In both cases the rule is the same: partial transection, never complete division — with cautery centrally, with scissors against the muscle laterally, about one centimetre, directed laterally and superiorly. Dividing completely does not improve the angle and does produce a palpable discontinuity.
Lateral platysmaplasty
- Supraplatysmal dissectionFrom the S-shaped incision to the sternocleidomastoid and thyroid line, running along the whole border and releasing the mandibular ligament
- Mark where to openThe gonion for the cervical ligament, and over the sternocleidomastoid so as not to injure the external jugular vein or the great auricular nerve. Infiltrate the subplatysmal plane first
- Subplatysmal planeDissect to the facial artery and free the platysma from sternocleidomastoid up to the thyroid cartilage. The cervical ligament is the hardest to divide properly
- Parotid tailIncision at the infralobular anterior border of sternocleidomastoid, dissection of the supraparotid SMAS and excision of the tail. Avoid dividing the platysma from the facial SMAS: tension over the gonion is lost, and with it the definition
- SuspensionTo the mastoid periosteum with 2/0 absorbable, at 80 degrees, with a mattress suture in the platysma to spread the tension. Two fixation points
- ClosureIrrigation, drains and tension-free skin closure, removing the excess passively
Leave fat on the flap here too
The same applies in the neck as in the face, and with more reason: a layer of fat must be left attached to the skin flap. If dissection goes flush, two things become visible in the medium term: the skin looks darkened because the platysma shows through, and contour irregularities appear. It is an easy mistake to make precisely when a slim neck is the goal, and the result is the opposite. Put differently: neck slimming is achieved beneath the platysma, not by thinning the flap.
Details that prevent complications
- When reducing the gland, the facial vein lies anterior to the artery: that is the landmark for not entering blindly.
- Marking the platysmal opening over sternocleidomastoid protects both the external jugular vein and the great auricular nerve.
- The external jugular vein is left attached to the deep plane when dissecting the platysma: it is not raised with the flap.
- If the neck is done separately in a limited technique, it is worth doing the contralateral side before closing so both can be matched.
- Transfixing sutures in the submandibular area at the gonion: they eliminate dead space and reduce haematoma and seroma. Removed at 3 days.
The goal, in five criteria
It is worth having the goal written down, because the neck is where it is easiest to chase an impossible image. A youthful neck meets five criteria: a defined mandibular border, a subhyoid depression, a visible thyroid cartilage, a visible anterior border of sternocleidomastoid and a cervicomental angle between 110 and 120 degrees. And one limitation to explain before operating: a low, anterior hyoid caps the angle achievable, however good the technique. Saying so in clinic turns an impossible expectation into a satisfactory result.
References
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Related specialty: Facial Lifting & Rejuvenation