The geometry of the neck is quite simple compared with that of the middle third of the face from the lower eyelid to the oral commissure. Therefore, one could logically assume that surgical correction of the aging neck would be straightforward, predictable, and enduring.

However, a review of literature as it pertains to surgical options in rejuvenating the neck reveals a variety of surgical approaches with the following similar goals:

• An acute cervico-mental angle;
• No visible soft tissue bulges (fat, muscle, and/or gland);
• Rhytids that are anatomically directed correctly; and
• Undetectable or minimally detectable scars.

What the Future Holds

These goals can be daunting given that, worldwide, the public wants less-invasive procedures, with minimal morbidity, few sequelae and complications, and a quicker recovery. When the superficial muscular aponeurotic system (SMAS) was described in 1976, many surgeons embraced this anatomy and used it to develop a series of aggressive approaches to rejuvenate the neck.

(1) The Quill SRS bidirectional barbed suture for midline platysmaplasty; (2) backcut of platysma muscle after midline approximation; and (3) lateral platysmaplasty with contouring of the neck.

Options included partial- or full-width transection of the platysma muscle with midline and posterior suspension. In aging necks with heavy soft tissue, and long and thick platysmal bands, this approach may be used.

Aging necks that have more modest deformities can be made to look "over-operated on" when these aggressive maneuvers are employed. Indeed, many aging necks can be corrected by limiting the incisions to the submental area, adding a small periauricular incision for posterior neck access.

In other cases, a pure vertical vector on the jawline with purse-string sutures—often combined with closed liposuction—will provide substantial improvement in neck contour, provided that the patient does not have long platysmal bands from the clavicles to the jawline.

In an attempt to provide a true cylindrical shape to the neck, some surgeons have advocated resection of the anterior belly of the digastric muscle and/or partial resection of a ptotic submaxillary gland. However, most surgeons are reluctant to add these maneuvers to their surgical armamentarium. Given the variety of options and the deceptively simple geometry, decision-making is complex.

The Four Categories

Having tried many of these techniques, I have developed a template for rejuvenation of the neck. My options have been significantly enhanced by the introduction of the Quill^® SRS^® (self-retaining system) bidirectional and unidirectional barbed sutures.

The aging neck can be defined in four categories, to which the surgeon can apply the following treatments:

The first type is the younger patients with mild blunting of the mandibular border with or without microgenia and submental lipodystrophy. In this case, the recommended treatment is ultrasonic-assisted liposuction with or without adding an anatomical chin implant.

Older patients with mild laxity of the submental area, with or without microgenia and submental lipodystrophy, make up the second category. Treatment is ultrasonic-assisted liposuction, unidirectional Quill barbed sutures, with or without adding an anatomical chin implant.

Next, we find older patients who exhibit the findings in the aforementioned second category and who have short, thin platysmal bands that end at the hyoid. The recommended treatment: closed liposuction and open neck contouring from submental incision incorporating the Quill SRS bidirectional suture system for midline platysma placation and contouring.

Before & After

Preoperative and postoperative lower face and neck lift with Quill SRS bidirectional barbed sutures for midline platysmaplasty, and additional jawline and subjaw contouring. The patient also underwent a SMAS platysma rotation flap.

Among those in the fourth category, treatment would consist of closed liposuction of the neck; preauricular, postauricular, and submental incisions with midline platysma plication and contouring with the Quill SRS bidirectional sutures; a backcut of the platysma muscles at or below the level of the cricoid cartilages, as well as an extended SMAS/platysma rotation flap and a double layer sling support of the neck utilizing the Quill SRS system.

Improved Results

The added suspension obtained via the use of barbed sutures placed from the mastoid fascia to the anterior/lateral platysma in the neck tightens the platysma muscle and improves the contour by supporting the submaxillary gland, producing a more acute cervico-mental angle. These sutures are a derivative of poly(_L-lactic) acid (similar to PDS) and are labeled as PDO. Tensile strength diminishes over time as absorption occurs during the first 6 months.

I was not impressed with the longevity of correction of the neck in purely closed procedures incorporating barbed suture technology, but I have been impressed with the quality of my results obtained by adding this emerging technology in hybrid and open procedures. Recovery time is not longer than what I observed prior to when I started using these methods.

Malcolm D. Paul, MD, FACS, is a clinical professor of surgery at the Aesthetic and Plastic Surgery Institute, University of California at Irvine. He can be reached at (949) 760-5047 or .