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3 Aspects Shaping Surgical Neck Rejuvenation

As minimally invasive facial rejuvenation procedures such as neuromodulators, fillers, and skin resurfacing gain traction, the neck has emerged as a focal point for patients seeking comprehensive aesthetic enhancements. Despite advancements in non-surgical modalities, surgical intervention often remains paramount for achieving enduring and aesthetically pleasing outcomes in neck rejuvenation. Physicians contemplating surgical alterations in this anatomical area must meticulously strategize their approaches to align with patient expectations, especially given the potential divergence between patient desires and achievable results through nonsurgical means. Notably, the jawline and neck contours exert substantial influence on perceived age, attractiveness, and overall body aesthetics. Patients frequently express a preference for a well-defined neck contour devoid of submental fullness, associating it with youthfulness and beauty.

Ensuring congruity between facial and neck aesthetics is imperative for achieving natural-looking outcomes in cervicofacial rejuvenation. Neglecting to address concerns in the neck region while focusing solely on facial enhancements may lead to an imbalance, typified by the "overdone-face underdone-neck" deformity, particularly evident in profile views such as the Connell view. Surgeons dedicated to optimizing facial rejuvenation must prioritize techniques tailored to enhance the neck and submental region, thereby fostering harmonious and balanced outcomes before embarking on isolated facial procedures.

Hence, in this blog, we will explore the intricate dynamics of neck aesthetics, delving into surgical nuances and innovative approaches to achieve harmonious cervicofacial rejuvenation.

I. The Surface Anatomy of the Neck

The neck and submandibular regions are crucial areas for aesthetic surgery, yet compared to other anatomical regions, they lack comprehensive descriptions of key surface landmarks guiding surgical modification. Despite variations in the perception of attractiveness among patients and surgeons, understanding the essential features of a youthful and attractive neck is imperative for specialists in aesthetic plastic surgery. Preoperative discussions with patients are essential to align expectations and achieve desired outcomes.

Submental-Cervical Angle

The submental-cervical angle is a crucial metric in assessing neck aesthetics and guiding surgical interventions, particularly in cervicofacial rejuvenation procedures. This angle, defined as the intersection between the line connecting the submental point (located at the most anterior midpoint of the soft tissue chin) and the cricoid cartilage landmark, offers valuable insights into the balance and proportions of the lower face and neck.

In technical terms, the submental-cervical angle reflects the relationship between the chin and the neck, which significantly impacts the perceived attractiveness and harmony of the cervicofacial region. A submental-cervical angle within the range of 90° to 105° is generally considered aesthetically pleasing, indicating a defined jawline and a youthful neck contour.

However, it's crucial to note that there are variations in the desired submental-cervical angle among patients and clinicians. While patients may perceive an angle of 110° as desirable, clinicians often aim for a slightly higher angle, around 125°, to achieve optimal surgical outcomes. This discrepancy underscores the importance of comprehensive preoperative discussions to align patient expectations with achievable results.

Clinically, the submental-cervical angle serves as a guide for surgical planning, particularly in procedures aimed at enhancing jawline definition and neck contour. Surgeons utilize this angle to determine the extent of tissue manipulation required to achieve optimal aesthetic outcomes while maintaining natural-looking results.

Moreover, variations in the anterior, lateral, and posterior submandibular-cervical angles provide additional insights into the nuances of neck aesthetics. These angles, derived from the submandibular-cervical junction line, help refine surgical strategies to address specific concerns such as submental fullness or loss of jawline definition.

Musculomandibular Triangle

The musculomandibular triangle is an anatomical landmark of significant importance in the evaluation and surgical planning of cervicofacial rejuvenation procedures. It is delineated by the anterior border of the sternocleidomastoid muscle, the lateral border of the mandible, and the anterior margin of the neck.

From a technical standpoint, the musculomandibular triangle serves as a guide for assessing the structural integrity and aesthetic proportions of the lower face and neck region. Its well-defined borders provide a clear demarcation between the muscular and bony structures of the mandible and the adjacent soft tissue of the neck.

Clinically, the musculomandibular triangle plays a crucial role in surgical interventions aimed at enhancing jawline definition and neck contour. Surgeons utilize this landmark to identify areas of excess soft tissue or laxity, as well as to plan the appropriate surgical techniques for achieving optimal aesthetic outcomes.

Furthermore, the presence of a well-defined musculomandibular triangle is indicative of a youthful and attractive neck contour. Its prominence contributes to the perception of facial harmony and balance, making it a key consideration in aesthetic assessments and surgical planning.

During surgical procedures such as facelifts or neck lifts, the musculomandibular triangle may be addressed through techniques aimed at tightening or repositioning the underlying musculature and removing excess soft tissue. By enhancing the definition of this triangle, surgeons can achieve a more sculpted and rejuvenated appearance of the lower face and neck.

II. The Submandibular Shadow

In facial aesthetics, the interplay of light and shadow plays a pivotal role in accentuating facial contours and defining anatomical features. Achieving a well-defined jawline is a cornerstone objective in surgical cervicofacial rejuvenation procedures. This entails creating a distinct demarcation between the mandible and the adjacent neck tissue to enhance the perception of a sculpted jawline. To visualize this, consider the anatomical prominence of the chin and mandible, which project anteriorly from the neck.

From a technical standpoint, the separation between the mandible and neck is most prominent in the anterior region due to the pronounced projection of the chin. However, attaining a comprehensive and aesthetically pleasing jawline requires attention to detail along the entire mandibular contour. This necessitates addressing submandibular structures such as excess adipose tissue, lax musculature, and redundant skin.

Surgical interventions aimed at enhancing the jawline typically involve strategic reduction of submandibular fat pads and tissue sculpting to create a harmonious transition between the mandible and the neck. By meticulously reshaping these anatomical elements, surgeons aim to optimize the distribution of light and shadow along the jawline, thereby enhancing its definition and attractiveness. Moreover, the principles of light and shadow in facial aesthetics have been extensively studied and applied in various cosmetic procedures, including rhinoplasty and breast augmentation. Extending these principles to lower face and neck aesthetics is essential for comprehensively understanding and refining jawline definition.

III. The Neck's Dynamic Anatomy

To optimize outcomes in neck lift surgery, a comprehensive understanding of the morphological intricacies of the youthful neck, both at rest and in motion, is indispensable. This necessitates an in-depth analysis not only of static anatomical landmarks but also of dynamic configurations, as the neck undergoes significant transformations during movement.

Observations of individuals with aesthetically pleasing necks reveal distinct differences in neck configuration when they look downward, compared to those with aging or less desirable neck contours. Specifically, in individuals exhibiting a youthful neck, a smooth and uninterrupted contour is evident beneath the mandible, devoid of a submental convexity or double chin. Instead, there exists a clear demarcation between two lines: a horizontal line tracing the jawline and extending beyond the neckline, and a vertical line along the anterior aspect of the neck.

Successful execution of a neck lift procedure hinges on the meticulous management of deep cervical structures to recreate these well-defined contours. The Connell view, offering a specific perspective on the neck, emerges as an invaluable tool for evaluating surgical outcomes post-procedure, particularly in the context of lower facial rejuvenation interventions. Oversight of this view may precipitate a discordance between facial and neck aesthetics, culminating in the undesirable "overdone-face underdone-neck" phenomenon.

Insights gleaned from dynamic cadaver dissection studies elucidate the pivotal role played by deep neck structures in shaping submental contours during neck flexion. These investigations unveil the displacement of submandibular glands and the anterior belly of the digastric muscle, contributing to soft tissue bulging beneath the chin. Such findings underscore the imperative of addressing these dynamic changes to achieve harmonious and natural-looking neck contours across diverse postures and movements.

Clinical validation of these anatomical dynamics is substantiated through dynamic MRI studies, which visually depict the displacement of submandibular glands and soft tissue bulging during neck flexion. Armed with this nuanced understanding, surgeons can adeptly navigate the complexities of neck rejuvenation surgery, ensuring the preservation of youthful and attractive neck contours in both static and dynamic contexts. This holistic approach not only enhances patient satisfaction but also elevates the overall efficacy and longevity of surgical outcomes in cervicofacial rejuvenation procedures.

Management of Deep Neck Structures

The management of deep neck structures is paramount in achieving optimal outcomes in neck lift surgery. Patients with type I facial aging, characterized by facial thinning, typically benefit from facelift procedures focused on elevating and tightening the superficial muscular aponeurotic system (SMAS)/platysma muscle complex, thereby enhancing jawline definition. Conversely, individuals exhibiting perifacial expansion and submandibular fullness indicative of type II facial aging require a reduction neck lift for effective jawline contouring. Dividing the submandibular region into three distinct zones allows for a systematic approach to addressing the anatomical structures within each zone. This division facilitates surgical planning and execution by providing a clear framework for targeting specific structures and achieving desired outcomes.

Zone I (Parasymphyseal Mandible):

  • Anatomy: This region extends from the midline beneath the anterior mental region of the mandible. It predominantly comprises superficial fat, with the platysma muscle lying superficially.

  • Surgical Approach: Liposuction is commonly employed in Zone I to address superficial fat accumulation. However, aggressive fat removal should be avoided to prevent exposure of platysma bands and irregularities in skin-muscle adherence. The thickness of the platysma muscle, particularly in male patients, necessitates careful management to prevent volume addition or central banding. Excision of excess muscle along the anterior border may be warranted before plication to achieve optimal outcomes.

Zone II (Body of the Mandible):

  • Anatomy: Zone II encompasses the area beneath the body of the mandible, extending from the parasymphysis to the angle. Superficially, it may include the jowl, while deeper structures comprise the submandibular gland (SMG).

  • Surgical Approach: Treatment in this zone is crucial for enhancing jawline definition. Direct excision (jowlectomy), microliposuction, or resuspension techniques are employed to address jowl prominence. However, the primary focus often revolves around managing the SMG, which is frequently enlarged and caudally displaced. Partial surgical reduction of the SMG, typically performed via an open neck approach, plays a pivotal role in improving jawline contours and achieving aesthetic balance.

Zone III (Angle of the Mandible):

  • Anatomy: This area lies below and behind the angle of the mandible, contributing to the posterior jawline definition and forming the retromandibular hollow or groove. Superficial fat is sparse, and prominence in this region is often attributed to the tail of the parotid gland.

  • Surgical Approach: Partial reduction of the tail of the parotid gland may be indicated to refine the posterior jawline contours. Differentiation of parotid reduction procedures, categorized into Type I, II, and III, is based on the extent of gland removal. Careful dissection techniques are crucial to preserve facial nerve integrity and minimize the risk of Frey syndrome postoperatively.

In conclusion, this exploration into the intricate dynamics of neck aesthetics has shed light on the essential considerations for achieving optimal outcomes in cervicofacial rejuvenation procedures. By delving into surgical nuances and innovative approaches, we have underscored the importance of meticulous planning and execution to attain harmonious results. From understanding key anatomical landmarks to addressing dynamic changes in neck contours, surgeons are equipped with invaluable insights to navigate the complexities of neck lift surgery effectively. Ultimately, by prioritizing patient-centered care and embracing comprehensive strategies, we can elevate the standards of aesthetic plastic surgery and fulfill the diverse needs of individuals seeking neck rejuvenation.


The Importance of the DeepStructures of the Neck to the Successful Neck Lift (2018)


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The Anterior Triangle of the Neck (2023)

Partial Removal of the Submaxillary Gland for Aesthetic Indications: A Systematic Review and Critical Analysis of the Evidence (2020)

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