Ptosis

Las Vegas -- When approaching cervicoplasty, a surgeon should never assume that a patient's excess fat is located only over the platysma. Instead, the surgeon should assume that the target dwells much deeper, according to Oscar M. Ramirez, M.D., F.A.C.S.

At the recent Facial Aesthetic Excellence meeting here, Dr. Ramirez pointed out two problems with traditional cervicoplasty. In addition to deep fat that dwells under the platysma, ptosis of the salivary glands is an area not routinely addressed by the conventional approach. To compensate for these deficiencies, deep cervicoplasty is now the technique of choice due to the lasting corrections it offers.

"Deep cervicoplasty was designed to remove fat between the digastric and platysma muscle, and beyond," says Dr. Ramirez, of the Esthetique Internationale Surgery Center, Baltimore, Md. "When you open the platysma you can remove this fat. Many patients have more in the deeper regions. With deep cervicoplasty, this can be addressed."

Plying away platysma

Deep fat located under the platysma extends laterally toward the salivary glands, and can be removed if approached by a deep plane. Through a submental incision of 3 cm or less, the surgeon can suture the platysma in the midline, but extra care should be taken with the salivary glands.

"If you pull out the salivary gland it may make the ptosis more obvious," Dr. Ramirez says. "When you complete the deep cervicoplasty, separate the platysma from the capsule of the salivary gland. Alternatively, you can complete a partial resection of the excess enlarged salivary gland."

Total removal of the salivary gland is not routinely recommended due to the possible creation of a cavity, or--in a small percentage of cases--a dry mouth. Yet, the partial excision of the gland can be safely completed through the deep cervicoplasty approach, according to Dr. Ramirez.

After separating the salivary gland from the platysma, the surgeon should approach from the outside of the platysma and imbricate the muscle with a neck suture suspension created by Dr. Ramirez. This has proven to provide better control.

"I designed a variation of the Guerrerosantos-Giampapa approach, which recruits the platysma over the weak portion of the salivary gland," Dr. Ramirez says. "These sutures are tied in a back-and-forth motion to the neck in two rows, allowing for better suspension of the salivary glands and the cervical jaw line."

Positioning the patient's head in the neutral position allows for better gauging of the degree of tension that is being applied and the changes at the cervico-submandibular "break" line. In cases with obvious salivary gland ptosis, the sutures are woven on the superficial fascia of the platysma overlying the gland, according to Dr. Ramirez.

"Most patients who undergo a traditional cervicofacial lift ask about the 'walnuts' that are left after the surgery. These are not fat; they are droopy, ptotic salivary glands that have become apparent after cleaning out the neck of surrounding fat," Dr. Ramirez says.

Deep cervicoplasty is best completed with Gore-Tex or Tevdek sutures, to ease tightness during neck rotation following surgery. Polytetrafluoroethylene sutures also allow the exclusion of strings, slings or membranes for additional support.

Disadvantages

The only drawback that deep cervicoplasty may present is one for the surgeon--and this only occurs when the surgeon's knowledge of the anatomical area is limited.

"Not every surgeon can engage in this procedure if they're not familiar with the anatomy and the approach," Dr. Ramirez says. "But, the benefits are well worth the training. Deep cervicoplasty addresses problems we were unable to address in the past. These issues, such as deep fat under the platysma, can be addressed with sound surgical steps, allowing you to tailor your approach to the patient's needs."

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