Safe Approach to Deep Plane Facelift: Vertical Midline Platysmaplasty with Extended Cervical Platysma Release
- jessilyntanhy9
- 7 days ago
- 5 min read
In the realm of modern facial rejuvenation, deep-plane face-lift surgery has earned its place as the gold standard for achieving natural, long-lasting outcomes. However, many plastic surgeons still approach this technique with hesitation—particularly when working in anatomical “danger zones” where vital nerve structures reside. A recent technique published by Timberlake et al. in Plastic and Reconstructive Surgery (April 2025) offers a transformative solution: a vertical midline platysmaplasty combined with extended low cervical platysma release. This novel approach not only enhances aesthetic outcomes from the menton to the clavicle but does so with heightened surgical safety.
In this article, we break down the surgical sequence, technical pearls, and safety advantages of this approach for surgeons eager to push their facelift results to the next level without increasing risk.
Why Rethink Traditional Platysmaplasty?
Traditionally, platysmaplasty techniques have raised concerns among deep-plane surgeons for one critical reason: they can limit vertical vector lifting, compromising the natural redraping of the jawline and midface. Moreover, lateral myotomies pose risk to cervical nerve branches and often fail to address the full length of platysmal descent.
The vertical midline platysmaplasty with extended lateral dissection addresses these shortcomings by:
Repositioning the platysma vertically (not transversely),
Avoiding lateral division, thereby preserving nerve safety,
Extending platysmal release up to 12 cm below the mandibular angle, which allows complete rejuvenation of the neck, including the lower cervical region.
Step-By-Step Surgical Procedure
Preoperative Planning & Anesthesia
Markings:
Transverse submental incision
Cervical borders to SCM
Mandibular angle and lateral canthus for deep-plane entry
Anesthesia Infiltration (Total 85 cc):
50 cc 0.5% lidocaine
30 cc 0.25% bupivacaine
0.4 cc epinephrine (≈1:200,000)
30 cc injected subcutaneously in the neck midline
25 cc each side for facial infiltration
Step 1: Midline Vertical Platysmaplasty
Incision
Transverse submental incision, a few mm anterior to the natural submental crease.
Dissection
Subcutaneous dissection proceeds to:
Inferiorly: Cricoid cartilage
Laterally: Just anterior to SCM borders
Elevate platysma flaps using electrocautery.
Excision
A central strip of platysma and subplatysmal fat is excised from menton to ~2 cm below the hyoid.
Muscle Sculpting
Address subplatysmal fat and anterior digastric muscles as needed.
Flap Suspension
Use a 4-point 3-0 Ethibond suture to secure platysma to mylohyoid fascia, advancing ~2 cm vertically.
The final, central suture incorporates a deep bite into menton periosteum.
Avoid submandibular gland excision — instead, treat postoperative gland ptosis with neuromodulators if needed.
Step 2: Deep-Plane Midface Dissection
Face is injected before dissection begins.
Incision & Flap Elevation
Standard deep-plane face-lift incision (preauricular/retroauricular).
Elevate the facial flap in the subcutaneous plane to deep-plane entry point.
Deep-Plane Entry
Use a No. 10 blade to cut through SMAS/platysma:
Entry is made ~2 cm superior to the mandibular angle.
This is a safe entry point due to presence of dense parotid capsule.
Dissection Pathway
Enter premasseteric space bluntly.
Blunt spread superficial to orbicularis oculi to expose zygomatic ligaments.
Ligaments are released sharply.
Carefully visualize zygomaticus major.
Continue superficial blunt dissection medial to this muscle in a superior-to-inferior direction.
Avoid going deep to the zygomaticus major to protect zygomatic and buccal branches.
Step 3: Extended Cervical Platysma Release
Dissection Objective
Extend lateral neck dissection to connect with submental dissection.
Technique Details
Use Bovie electrocautery (setting: 8, coagulate mode).
Elevate platysma flap inferiorly, carefully observing for lip twitches—an indicator of proximity to:
Marginal mandibular nerve
First cervical branch
Dynamic Safety Check
If lip twitching occurs, immediately stop dissection.
Low Bovie settings enable thermal-sparing nerve monitoring without formal nerve stimulation.
Extent of Release
Elevate 5 to 12 cm of platysma from its attachment along anterior SCM.
Proceed to subplatysmal dissection off the deep cervical fascia.
Use blunt spreading if a cervical nerve is encountered — never apply traction.
Flap Continuity
Result: A contiguous SMAS/platysma flap from midface to lateral neck.
1–2 cm flap margin is dissected off the skin for tension-free fixation.
Step 4: Platysma/SMAS Fixation
Vertical Redraping
Platysma is redraped vertically, allowing full-length elevation without lateral myotomy.
Suture Points
2 figure-of-8 Ethibond sutures placed:
Platysma → mastoid fascia (cervical)
SMAS/platysma → parotid fascia (facial)
Final fixation near lateral canthus: SMAS/platysma → temporal fascia
Knot Management
Any palpable knots are oversewn with 4-0 Monocryl for smoothing.
Final Adjustment
Midline platysmaplasty is rechecked.
If needed, excise small bilateral triangle of platysma at hyoid level to refine redraping.
Step 5: Closure and Postoperative Care
Skin flaps are trimmed to match vertical vector.
Closure performed in layers.
Neck suctioned with Frasier tip to remove pooled blood.
Dressing applied.
Why Vertical Midline Platysma Release is a Safer, More Effective Choice
Feature | Traditional Techniques | Vertical Midline + Extended Release |
Platysma Elevation | Transverse, lateral | Vertical, midline + deep |
Neck Rejuvenation | Menton to thyroid | Menton to clavicle |
Nerve Risk | High (with lateral myotomy) | Low (no division, dynamic nerve monitoring) |
Anatomical Safety | Variable | Dense fascial planes, real-time monitoring |
Aesthetic Lift | Limited by tethering | True vertical vector with full redraping |
Key Advantages: Safety & Efficacy of the Vertical Midline Approach
Anatomical Preservation
Avoids blind or deep lateral myotomies. Instead, it uses direct visualization and conservative dissection to preserve motor nerve branches.
Complete Vertical Rejuvenation
Traditional deep-plane facelifts often fall short below the thyroid notch. This method enables full rejuvenation from the menton down to the clavicle—restoring the entire cervicomental contour.
Reduced Nerve Injury
Across 450 consecutive cases using this technique, no permanent nerve injuries were reported. Only 2 cases of temporary cervical neurapraxia, both of which resolved by week 6.
Incremental Learning Curve
Ideal for surgeons at all experience levels. Beginners can start with limited medial release, gradually extending deeper and wider as familiarity with the anatomy grows.
Conclusion
The vertical midline platysmaplasty with extended low cervical release represents a paradigm shift in deep-plane neck rejuvenation. By respecting neurovascular anatomy and eliminating the need for lateral platysma division, this technique achieves powerful aesthetic results with remarkable safety. Surgeons benefit from clear anatomical landmarks, dynamic nerve monitoring, and a single-plane composite flap spanning the face and neck. Most importantly, this method enables true vertical vector lifting—offering patients rejuvenation from menton to clavicle without compromise. For both seasoned and early-career surgeons, adopting this approach may offer a significant leap forward in deep-plane facelift outcomes.
Reference:
Timberlake, Andrew T. MD, PhD1; Cameron Brawley, Craig MD, MS, MBA2; Paul, Benjamin C. MD1; Rosenberg, David B. MD1. Complete Platysma Muscle Suspension in Deep-Plane Face-Lift Surgery. Plastic and Reconstructive Surgery 155(4):p 699e-703e, April 2025. | DOI: 10.1097/PRS.0000000000011705
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