Commentary

Previously, facial rejuvenation and lasting improvement of the neck seemed close to being a problem that we, as aesthetic surgeons, had “solved.” With the teachings of Connell,1, 2, 3 Feldman,4 Guerrerosantos,5 and others, we could obtain an excellent cervicomental angle even in obtuse angle between the chin and hyoid. To obtain those good results, it was necessary to undermine the entire neck, from above the horizontal ramus of the mandible to below the hyoid. The fat from on top of the platysma was suctioned or surgically removed; we then tightened the platysma both laterally and in the midline, thereby creating a sort of a “hammock” effect. During this procedure, it was advisable to cut part of the platysma on each side at the level of the hyoid, in order to avoid seeing or feeling a vertical cord. To accomplish this task, a submental incision was essential, along with wide undermining. As successful as we were at achieving good clinical results, there were problems with this approach—namely, extensive undermining, the bleeding caused by cutting the platysma (particularly if the anterior jugular veins were injured), and the higher incidence of hematoma.

I welcome Dr. Gonzalez's potential solution to these problems. His approach limits the undermining and avoids the submental scar. From a mechanical point of view, the author is correct: tractioning the divided platysma will carry the attached (nonundermined) skin and create a satisfactory cervicomental angle. The author's photographic results are good examples of the effectiveness of the procedure.

On certain points, however, I do have some concerns or differences of opinion with the author. First, although Dr. Gonzalez correctly indicates that the platysmal bands are lateral and not in the midline of the neck, most patients point to the submental “glob” as the area they want addressed. In my experience, at least in some cases, this requires liposuction on top of the platysma. I do not know how effective subplatysmal suctioning will be in those instances. Secondly, with this procedure, there is less undermining, and surgeons can avoid the submental incision. While that is a positive feature, I doubt whether the procedure is as simple as the author indicates. In particular, the guidelines to avoid the mandibular and cervical branches of the facial nerve are cumbersome. The landmark of the second premolar may be appropriate for an oral surgeon, but it is less useful for a plastic surgeon. I wonder if the author could prospectively correlate the distance from the midline of the neck to the location of the platysmal incision, as determined by the line from the premolar point. If the safe distance could be determined, it would be of considerable use to a plastic surgeon. Furthermore, if less undermining is desirable, why not traction the platysma at its lateral border, near the anterior edge of the sternocleidomastoid muscle? Could it be just as effective? I allow that the bulging submandibular gland may not be as effectively flattened, but it would be both faster and safer.

I agree that the platysmaplasty should be performed in conjunction with a midfacelift. Otherwise, the patient will be left with persistent jowls and may complain (as has been said to me) of looking like “a chipmunk with a kernel in its mouth.” However, it appears that the composite platysmaplasty was not always effective in correcting the platysmal bands, because the author had to perform a closed platysma myotomy on 17 patients (13%). It is the more severe bands which we aim to ameliorate.

Concerning the closed platysmal myotomy, I was impressed with the author's technique. Although it was developed years ago, I was not familiar with it before reviewing Dr. Gonzalez's article. It appears simple and probably applies to thin patients and to those with recurrent bands after a facelift. I do not know about its longevity; most likely, when performed as an isolated procedure, the bands will recur.

I do think that Dr. Gonzalez has given us a procedure which I, for one, will try on some of my patients, particularly those who do not want a submental incision. As is true of all innovations, general use of the closed platysmoplasty by a greater number of plastic surgeons will be the best reward for the author's effort.