Treatment of the jawline, mandible and neck area

Initial neck treatment involves correction of submandibular and submental lipoptosis. Type I facelifts require virtually no intervention on the neck. Posterior tightening of the skin-VMA-platysma complex is all that is required for the average patient. However, in most patients, attention should be paid to lipoptosis in the submental, submandibular, and mandibular areas.

If only a reduction in the volume of this drooping fat is required, a 1 cm incision is made in the submental area to allow a liposuction cannula to pass through. If the examination shows that there is no excess subcutaneous muscle and the skin retains some elasticity, liposuction is performed as the only procedure. First, a 1 cm dissection is made immediately under the skin, in the middle of the subcutaneous fat layer. Small (1 cm) tunnels are formed into which 2-3 mm diameter liposuction cannulas are then inserted. First, tunnels are created from the submental area through the edges of the mandible into the cheek area, to the anterior edges of the sternocleidomastoid muscles and down through the cervicomental angle to the thyroid cartilage area without the use of suction. This is done in a fan shape, from one cheek through the neck to the opposite cheek. A round cannula with three holes on one side is then used to perform liposuction. Very gentle and judicious liposuction is performed in the cheek area, with tissue retraction from the edge of the mandibular bone to avoid injury to the mandibular nerve. Minimal, uniform liposuction is performed to avoid creating any grooves, tunnels or depressions. These are most likely to occur in the cheek areas, so special care must be taken here. Depending on the amount of liposuction required in the submental and submandibular areas, a larger cannula may be required. A 4 mm or sometimes a 6 mm flat cannula with one hole on the underside is required to achieve adequate fat removal and contouring. Bimanual palpation is required to check for uniformity and symmetry of fat removal. A thin layer of subcutaneous fat must be left to give the skin a soft, natural contour. It is necessary to ensure that the volume of liposuction in the chin-neck angle area is not too large, as this can cause damage to the skin and subcutaneous scarring with subsequent development of striations.

Often this is all that is required in a Type II surgical facelift. However, in an extended Type III facelift, performed when there is a large amount of fat and some sagging of the platysma muscle, as well as in Type III, with significant accumulations of fat, sagging skin and platysma muscle, additional work is required. This involves widening the incision to at least 2.5-3 cm. Then, after liposuction, a direct lift of the skin over the platysma muscle is performed. This is done widely, usually to the anterior edges of the sternocleidomastoid muscles and beyond the cervicomental angle, which allows the surgeon to directly see the remaining areas of lipoptosis under the platysma muscle, as well as the excess and weakness of the anterior bundles of the platysma muscle. Their divergence is very clearly visible. The excess and weakness of these tissues are established. Using a grasper and a long curved Kelly clamp, the tissues are pulled to the midline. Their excess is excised with adequate hemostasis. The anterior edges of the subcutaneous muscle are then sutured together along the midline. Excess fat and muscle are removed all the way back to the cervicomental angle. Several 3/0 Vicryl mattress sutures are placed. Once a strong muscular corset and a sharper cervicomental angle have been created, the entire mass of skin remaining for tightening can be undercut from behind. Excess skin in the submental area will be placed at the end of the operation, after bilateral posterior and posterior auricular skin tension is applied posteriorly and superiorly.