During the last week of August, MAFAC’s Tagliacozzi Research Fellow, Dr. Lennert Minelli, visited Dr. Francisco Gomez Bravo in Madrid, Spain. The world-renowned neck-lift specialist had the week fully packed with extensive surgeries and new international patient intakes, as well as Spanish culture and a gourmet dinner. The entire experience was at a level that can only be expected of a master surgeon.

A brief summary of the surgical innovations that were learned by our Tagliacozzi Fellow are described below for the interest of the MAFAC faculty and members. Due to the extensive number of innovative techniques, the following report will focus primarily on the unpublished innovations in platysma surgery, not on the techniques of the submandibular gland, parotid gland, digastrics, or management of the adipose layers.

Surgical innovations

An important preoperative marking is the future SC junction line (submandibular-cervical junction line), which separates the submandibular and cervical segments of the neck, will end up higher on the neck as a result of the neck lift. A lateral manual traction maneuver performed on the skin of the neck while having the patient flex the neck will uncover the level of this line which is then marked.

In the submandibular segment (superior to the SC junction line), a subcutaneous dissection is performed through a submental incision, leaving a layer of subcutaneous fat on the platysma, as well as a sub-platysmal dissection, also leaving a layer of subplatysmal fat on the platysma, to completely free the platysma from its attachments. This is especially important at the level of the hyoid, as care taken to preserve a layer of subplatysmal fat avoids an excessively sharp cervico-mental angle postoperatively. [Note the aesthetic emphasis on avoiding sharpness here.]

In the cervical area, a deep dissection only and no subcutaneous dissection is carried out. Importantly, the dissection is not performed sub-platysmal but sub-fascial: that is, deep to the deep fascia, continuing laterally to the sternocleidomastoid muscle and inferiorly down to and slightly past the lowest neck crease that is aimed to be treated. The depth of this sub-fascial dissection has two main purposes: (A) the cervical flap is thick and composite comprising of the skin (Layer 1), subcutis (Layer 2), platysma (Layer 3), and deep fascia (Layer 5) preventing irregularities and skin webbing after redraping, and (B) the subsequent surgical connection of the subcutaneous dissection of the submandibular segment above the SC junction line with the sub-fascial dissection below the SC junction line results in a complete transection not only of the platysma, but also of the deep cervical fascia. As the cervical branches of the facial nerve run within the deep fascia, this musculo-fascial transection results in a complete denervation of the cervical platysma.

In the submandibular segment, the medial edges of the platysma are not joint by a simple corset, but rather the lowest part of the medial edges are brought over as far as possible with trimming of any excess and anchoring the medial edges of the platysma to the anterior digastric muscle and to the perihyoid fascia with the corset. The cervical segment of the platysma is suspended laterally to the mastoid fascia by inter-locking cable sutures later in the surgery, bringing the medial edges further apart. These maneuvers on the submandibular and cervical segment of the platysma cause a Z-plasty, bringing the cranial and caudal segment of each medial platysma band as far away from each other as possible (see Figure).

The cervical segment, consisting of the thick composite fascio-musculo-cutaneous flap, is lifted and suspended to the perihyoid fascia. This maneuver again has two main effects: (1) the thick composite flap provides adequate soft tissue padding of the thyroid cartilage and prevents medial window shading of the platysma, and (2) because of the previous extensive undermining of this composite flap, this lift permanently rearranges the platysma and overlying skin creases into slightly different positions, which seems to improve their depth and dynamic activity postoperatively.

The result of these innovative surgical maneuvers on the platysma and its innervation is a long-term benefit on the dynamic and resting neck skin quality, with less deep wrinkles and creases and smoother contours.

The Melbourne Advanced Facial Anatomy Course hopes to welcome Dr. Bravo to a dissection course in the near future and will notify its members when more information becomes available. For more information and insights into the techniques of Dr. Bravo, please contact MAFAC or Dr. Minelli.

References

  • Bravo FG. Reduction Neck Lift: The Importance of the Deep Structures of the Neck to the Successful Neck Lift. Clin Plast Surg 2018 Oct; 45(4):485-506
  • Bravo FG. Neck Contouring and Rejuvenation in Male Patients through Dual Plane Reduction Neck Lift. Clin Plast Surg 2022 Apr; 49(2):257-273