The objective of facial surgery and neck rejuvenation is to achieve a natural, natural result. This is only possible with good knowledge and analysis of the aging process. Surprising and unexpected results of the study of the aging process led specialists to radically modify the surgical method of neck rejuvenation. Some previous surgical concepts have been validated while others have been considered and rejected. In addition, this logic led to the emergence of a technique (SPMA) for fixing the skin and platysma muscle.
Alan Fogli
- Professor of the International Association of Aesthetic Plastic Surgeons ISAPS;
- Honorary President of the National Organization for Plastic, Reconstructive and Aesthetic Surgery;
- Member of the French Association of Plastic, Reconstructive and Aesthetic Surgeons;
- Member of the Argentine Association (Buenos Aires) for Plastic, Reconstructive and Aesthetic Surgery;
- Founder of Clinique de chirurgie esthetique du docteur Fogli Alain, Marseille (France).
About the peculiarities of this technique, readers estet-portal.com are offered a summary of the article by Professor Alan Fogley (France) about his own view on the fixation of the skin and cervical muscle.
Features of muscles and skin, their consideration in neck rejuvenation
Anatomically, the subcutaneous cervical muscle consists of two parts: the front part and the cervical part. Correction of the ligaments of the platysma muscle requires vertically directed vectors at the facial level. The periosteum of the zygoma and the anterior margin of the parotid fascia are two significant structures that do not change with aging. They provide an opportunity to fix sagging tissues, including pre-zygomatic fat pads, cheeks and ligaments of the subcutaneous cervical muscle.
The ligaments between the skin and the platysma muscle are not affected, although most of the facelift techniques require the separation of the platysma muscle from the skin and suturing the anterior margin using a submental approach. Moreover, the posterior border of the subcutaneous cervical muscle does not change due to aging. This explains why it makes no sense to separate this structure. The principles of technology discovered as a result of new research are fundamentally special.
Lore's fascia is used as a guide to approach the facial nerve trunk. Labbe and colleagues conducted an anatomical study of this procedure, which allowed firm fixation of the subcutaneous cervical muscle without separating it from the skin. This has become a key moment for operations, because the skin and muscle are lifted inseparably. Non-separation of the skin and muscle, especially at the cervical level, is an effective means for correcting the subcutaneous cervical ligaments and for accurately determining the angle between the neck and chin.
Principles of neck rejuvenation intervention
This operation is based on the concept of moving tissues to the places where they are in young people. (Fig. 7-9). The first part of the surgery is the firm attachment of the platysma, which is a skin muscle, to the prelobar fibrous tissue. But this fixation alone is not enough to achieve the desired position. The next steps in this operation release the excess tension and bring the platysma muscle into position.
The advantages of using a continuous suture should be emphasized. This allows better distribution of tension and avoids the comb aspect that occurs when using separate seams. The concept of a close approach to correctable skin lesions is extremely effective. Indeed, detachment of the SMAS in the upper part of the parotid surface is of no interest, since the parotid aponeurosis does not weaken with aging.
Fig. 7. (a, b) Preoperative photo of a 63-year-old woman. (c, d) View 2 years after the skin and platysma muscle pinning technique with temporal lift by galeapexy, with upper and lower blepharoplasty. (e, f) Photos taken during surgery. The amount of excess skin without any tension demonstrates the effectiveness of the technique
Fig. 8. (a, b) Preoperative photo of a 61-year-old male with significant muscle and skin laxity of the face and neck, with wrinkled skin on the lower neck. (c, d) View 15 months after application of the skin and platysma muscle pinning technique without submental approach. (e, f) Enlarged view before and after surgery of the angle between the neck and the chin and the lower part of the neck.
Fig. 9. (a, b) Preoperative photographs of a 59-year-old woman. (c, d) View 11 months after platysma skin and muscle fixation technique with temporal lift with galeapectomy, upper and lower blepharoplasty, and earlobe reconstruction
Securing the SMAS after deepening or resection at the anterior border of the parotid fascia is particularly effective. Indeed, the place of fixation is located near the site of damage, nasolabial folds, vertical wrinkles going from the corners of the lips to the chin and the front of the platysma bands are corrected. Treatment of these lesions requires an almost vertical facial vector. Thus, the tension created at the level of the prelobar fibrous tissue should not act on them for a long time. In addition, a large number of anatomists believe that the separation between the face and neck is at the level of the digastric muscle. Not surprisingly, the submental platysma can be effectively treated at the facial level in more than 85% of cases.
This technique does not form a simple plication, which has been suggested for a long time. In fact, plication is carried out within flaccid tissue, or between flaccid and mobile tissues. It stretches from one side to the other without fixation. The proposed technique is significantly different and attaches movable tissues to fixed structures. The absence of extensive compartments gives advantageously a large connection surface.
A significant excess of skin is not the goal, but merely proof of the effectiveness of these fixations. Thus, the skin is not devitalized and the pain becomes less. And finally, a hematoma, if it appears, will be significantly limited in its distribution.
However, if such good results can be achieved with less separation, less risk, and less pain, then it is fair to use this technique in most cases. In addition, a trend can be clearly traced in the works of several authors with extensive practice. They choose to perform procedures with optimal efficiency, enabling patients to return to social life more quickly.
Submental level results are equivalent in percentage to those seen with other techniques when using the submental approach with large muscle flaps. Even in these cases, the contour of the neck and the angle between the neck and chin always looked natural, while invasive techniques gave an unnatural surgical appearance. For improved results, direct skin resection proved to be the most logical, and reoperation showed excellent tension in the platysma muscles (Fig. 10).
Fig. 10. (a, b) Pre-op photos of a 73-year-old woman who had pronounced tissue laxity between her neck and chin. (c, d) View 6 months after application of the platysma skin and muscle attachment technique, with temporal lift and galeapexy, upper and lower blepharoplasty. The improvement is distinct, but the angle between the neck and chin is slightly emphasized. A direct resection of excess skin is required. (e, f) View 14 months after surgery. The submental approach allowed a good division of the platysma muscles on either side of the midline of the neck. They did not require surgery
However, resection of thick bands of platysma without a suture can be performed in a very small number of cases. In other cases, as recommended by Labbe, injection of botulinum toxin into other submental platysma bands can be managed, confirming the phenomenon of retraction during aging.
Thus, a better understanding of the aging process, and especially a better knowledge of changes in the skin, muscle and adipose tissues, leads to the development of new concepts. The study of the results of their application shows the same effectiveness and even better results in most cases using a non-invasive, safer technique, giving a natural result. With this concept, the anatomical foundations remain indispensable to the surgeon, but should not be carried out systematically, because the same result can be achieved with less pain. Finally, if the surgeon wants to achieve a natural result, he must not create a new anatomy. Thus, the movement of tissues should reproduce the natural anatomy of young people. SPMA achieves this goal.
Read also: "Special Facial Rejuvenation and Platysma Lift"
Details about his own method of correcting age-related changes in the area of platysma and some structures that allow to keep the muscles of the face in a tightened state were presented by Alan Fogli at the ISAPS World Congress, 19-20 May 2017, Kyiv, Ukraine .
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