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Surgical Technique |

Direct Submentoplasty for Neck Rejuvenation

John B. Bitner, MD; Oren Friedman, MD; Richard T. Farrior, MD; Ted A. Cook, MD
Arch Facial Plast Surg. 2007;9(3):194-200. doi:10.1001/archfaci.9.3.194.
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Facial plastic surgeons commonly see patients with submental laxity and an excess of skin and fat in the upper neck. This has colloquially been called the “turkey gobbler” deformity. In some cases, this deformity is the patient's only aesthetic concern, and full face-lift surgery is not desired. In this study, we reviewed the English-language peer-reviewed literature for descriptions of direct excisional submentoplasty techniques. Various designs for skin excision and wound closure have been used by surgeons over the past several decades. This article summarizes the surgical technique as well as the advantages and disadvantages of each method. Furthermore, we propose an approach that incorporates many of the other designs but to our knowledge has not been described previously in the peer-reviewed literature. An understanding of these numerous approaches will better enable facial plastic surgeons to appropriately address and correct patient aesthetic concerns.

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Figure 1.

Illustration of degrees of age-related cervicomental changes. Adapted and modified from the 1980 description by Dedo.12 A, Class I, showing a well-defined cervicomental angle with little fat and good skin and platysma tone. B, Class II, showing mild laxity of the cervical skin without significant fat deposition or muscle looseness. C, In class III a layer of subcutaneous fat is present. Liposuction is usually required to improve the cervical contour. There is adequate skin and muscle tone so that lipocontouring yields good results. D, Class IV shows varying degrees of platysma dehiscence and weakness best seen with voluntary facial grimacing. Anterior cervical cording is often visible, and surgical manipulation of the platysma may be helpful. E, In class V, patients have retrognathia that contributes to their neck fullness and may require chin augmentation or mandibular osteotomies. F, Class VI, showing abnormal hyoid position, most often a low-lying hyoid that obscures the cervicomental angle. Neck results from any surgery will be limited owing to this anatomical variant. Used with permission of Mayo Foundation for Medical Education and Research.

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Figure 2.

Lazy H–shaped incision. A, An incision is made by marking 1 vertical and 2 horizontal incisions. The center segment of skin is excised and discarded. B, The lateral flaps are undermined and advanced to the midline, and the incision is closed with a Z-plasty. The appearance of the incisions is that of an H lying on its side. Used with permission of Mayo Foundation for Medical Education and Research.

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Figure 3.

T-Z–plasty. A, An incision is created by first excising an ellipse of skin in the submental crease. A vertical incision is then made inferior to the ellipse, and the flaps are undermined. B, The excess lateral skin is excised and discarded. C, Excess fat and platysma also are often treated at this step. D, The vertical limb is closed with a Z-plasty. Dog ears at the inferior extent of the incision may be corrected with another elliptical excision. Used with permission of Mayo Foundation for Medical Education and Research.

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Figure 4.

W-plasty. A, Horizontal markings are made at the level of the submental crease and the suprahyoid crease. The horizontal incisions are made, and a vertically oriented W-plasty is designed. The central strip of excess skin is removed, preserving the W-plasty configuration. B, The W-plasty is closed. Used with permission of Mayo Foundation for Medical Education and Research.

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Figure 5.

Vertically oriented elliptical excisions with a T closure. A, A vertically oriented central ellipse of skin is marked and removed with the apex of the ellipse at the submental crease; the inferior point varies depending on the pathologic characteristics. B, An acutely angled triangle of skin is then removed between the submental crease and the superior portion of the ellipse. Platysma and fat are then addressed. C, The skin edges are reapproximated and closed. D, The final closure is T shaped. Used with permission of Mayo Foundation for Medical Education and Research.

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Figure 6.

Bilateral hemi-ellipse. A, A vertically oriented ellipse is marked. A midline vertical incision is made connecting the apices of the ellipse. The superior portion of one half of the ellipse is excised together with underlying excess fat. A similar procedure is performed on the inferior segment of the contralateral half of the ellipse. Once undermined, platysmal plication and excess fat removal can be performed. B, Final closure leaves a scar similar to a Z-plasty. Used with permission of Mayo Foundation for Medical Education and Research.

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Figure 7.

Grecian urn technique. A, A vertically oriented ellipse of skin is marked. The superior apex is positioned at the submental crease, and the inferior portion varies but may extend to the thyroid notch or below. Symmetrical horizontally oriented ellipses are marked at the inferior and superior vertical ellipse apices. The final incision marking appears similar to an ancient Grecian urn. A 60° 1.0- to 1.5-cm Z-plasty is marked at the cervicomental angle. B, Incisions are created, and undermining is performed in a supraplatysmal plane. The platysma is plicated to the thyroid notch. The skin is closed according to the indicated arrows. C, The final closure results in scars generally well disguised in natural submental creases. Used with permission of Mayo Foundation for Medical Education and Research.

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