COSMETIC

A 26-Year Experience with Vest-over-PantsTechnique Platysmarrhaphy

Bahman Guyuron, M.D.Eman Yahya Sadek, M.D.

Rouzbeh Ahmadian, M.D.

Cleveland, Ohio

Background: The purpose of this article is to review the efficacy of the vest-over-pants technique for elimination of the platysma bands and improvementof the cervicomental angle.Methods: This is a retrospective chart review of 88 patients with neck aging selectedrandomly by a visiting fellow and a medical student. The collected informationincluded patient demographics, cervical surgical techniques, and complications.Patient photographs obtained preoperatively and at least 8 months postoperativelywere compared on front and profile views to determine the visibility of the platysmalbands and the neck contouring. Through an incision placed anterior to the sub-mental crease, the platysma borders were identified and elevated. After completionof the other intended procedures, the platysma borders were then overlapped usingthe vest-over-pants technique with 4-0 Mersilene.Results: The mean patient age was 57.56 years. There were 76 women (86.4percent) and 12 men (13.6 percent). The average follow-up was 28.8 months.Of the 88 patients, 93.2 percent underwent concomitant rhytidectomy, 94.3percent underwent submental lipectomy, 95.9 percent underwent subman-dibular contouring, 61.4 percent underwent removal of the anterior belly ofthe digastric muscle, and 5.7 percent underwent suspension or partial or totalexcision of the submandibular salivary gland. None of the patients hadresidual recurrence of the platysma bands during the follow-up period.Conclusion: On the basis of the detailed analysis of this group of patients and26-year experience with this technique, the authors conclude that this proce-dure provides logical and enduring elimination of prominent platysma bandsand suspension of neck structures. (Plast. Reconstr. Surg. 126: 1027, 2010.)

Most patients who seek facial rejuvenation aremore concerned about the neck areathan the rest of the face. Ellenbogenand Karlin have outlined the criteria for a youth-ful neck, including a distinct inferior mandib-ular border, a visible subhyoid depression, avisible thyroid cartilage bulge, a visible anteriorsternocleidomastoid muscle border, a submen-tal-sternocleidomastoid line angle of 90 de-grees, or a cervicomental angle of 105 to 120degrees.1 Characteristic signs of the aging neckinclude skin laxity, an obtuse cervicomental an-gle attributable to subplatysmal and suprapla-

tysmal fat deposits, prominent anterior belly ofdigastric muscles,platysmalbands,andpossibleptosisof the submandibular gland. These imperfections maybe associated with a low-set prominent hyoid, jowls,obscured mandibular border, and receding or ptoticchin. Often, a varying combination of these flaws co-exist (Tables 1 and 2).

In this article, we report a technique of pla-tysmarrhaphy that has been used by the seniorauthor (B.G.) over the past 26 years. The chartsand full sets of photographs of patients selectedrandomly by a visiting fellow, without the directinvolvement of the senior author, were analyzed toreview the outcomes associated with this proce-dure, which is the subject of this report.

From the Department of Plastic Surgery, University HospitalsCase Medical Center and Case Western Reserve University.Received for publication November 2, 2009; accepted Feb-ruary 16, 2010.Reprinted and reformatted from the original article publishedwith the September 2010 issue (Plast Reconstr Surg. 2010;126:1027–1034).Copyright ©2012 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e318265b805

Disclosure: The authors have no financial inter-est or commercial association that is related di-rectly or indirectly to the scientific work reported inthis article.

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PATIENTS AND METHODSThis is a retrospective study that includes a

chart review of 88 patients with aging neck whounderwent neck contouring performed by the se-nior author between 1999 and 2006. These pa-tients were selected randomly by a visiting fellowand a medical student. The random selection in-volved picking the charts of available patients fromthe different years without knowledge of the re-sults and the outcome of the operations. Neckcontouring with the vest-over-pants technique wasperformed in all patients. Patients with cervico-mental dysmorphologies or neck aging signs un-derwent either rhytidectomy and neck contouringor neck contouring alone. Standardized patientphotographs (frontal, lateral, oblique, and flexedneck) had been obtained preoperatively and atleast 8 months postoperatively. Each neck agingparameter was separately classified preoperativelyand postoperatively as none, mild, moderate, orsevere. Using Ellenbogen’s criteria, preoperativephotographs were analyzed by an independentobserver (visiting fellow) regarding the aging signsof the neck with a more intense focus on theplatysma bands. Postoperative photographs wereanalyzed and the surgical outcome was classified asexcellent, good, fair, and poor in terms of theoverall neck contour. Patients younger than 30years, patients with postoperative follow-up lessthan 8 months, and those with associated cranio-facial anomalies were excluded. The presence andseverity of the platysma bands was recorded. Allpatients underwent platysmarrhaphy, even thosewho did not exhibit prominent platysma bands, toimprove the neck contour following lipectomy.

Surgical TechniqueA 3.5-cm submental skin incision is designed

approximately a few millimeters anterior to the ex-isting submental crease. The submental and sub-mandibular areas and lateral neck are injected su-perficially and in the deeper planes using lidocainecontaining 1:200,000 epinephrine. Subcutaneousdissection of the neck is performed from the men-tum anteriorly to the thyroid cartilage caudally andfrom the midline to the mandibular angle laterally.A reasonably thick skin flap is elevated to minimizeirregularities and excessive skeletonization. Lateraldissection is performed through either a submentalincision or periauricular incisions, when this surgeryis performed concomitantly with rhytidectomy. Sub-mandibular contouring is performed using a lipo-suction technique only if the plan includes isolatedsubmental contouring. Otherwise, the lateral neckand the submandibular area are contoured underdirect visualization through the rhytidectomy inci-sion. Although adequate fat is left under the skinflap, the remaining fat attached to the platysma isremoved thoroughly. This is followed by identifica-tion of the platysmal borders. The platysmal bordersare separated and retracted laterally. Subplatysmaldissection is carried out to expose the subplatysmalfat and anterior belly of the digastric muscles. Thesubplatysmal fat is removed completely only if re-moval of the anterior belly of the digastric musclesis planned. Otherwise, the subplatysmal fat is re-moved partially and conservatively to avoid submen-tal hollowing. Complete or partial excision of theanterior belly of the digastric muscles using coagu-lation cautery is performed if the patient has a sig-nificant enough obtuse neck and malpositionedhyoid bone. The submaxillary glands are sus-pended if the glands are ptotic. Partial or com-plete removal of the gland is indicated rarely whenthe glands are hypertrophic.

While standing above the head, a 4-0 Mer-silene suture (Ethicon, Inc., Somerville, N.J.) ispassed through the lateral portion of the rightplatysma approximately 3 cm from the posteriorborder of the symphysis and, on average, 3 cmfrom the middle border, depending on the laxityof the platysma muscle (Fig. 1, above, left). Thesuture is then passed close to the medial border ofthe left platysma (Fig. 1, above, right). The suture

Table 2. Medial Platysmal Band

None (%) I (%) II (%) III (%) IV (%) p

Preoperatively 15 (17.0) 31 (35.2) 23 (26.1) 13 (14.8) 6 (6.8) 0.000Postoperatively 88 (100) 0 (0) 0 (0) 0 (0) 0 (0)

Table 1. Concomitant Procedures

Procedure No. (%)

Platysmarrhaphy 88 (100)Rhytidectomy 82 (93.2)Submental lipectomy 83 (94.3)Liposuction 4 (4.5)Submandibular contouring 84 (95.9)Removal of anterior belly of digastric 54 (61.4)Caudal transection of platysma 15 (17.0)Suspension of submandibular salivary gland 2 (2.3)Partial or total excision of

submandibular salivary gland 3 (3.4)Genioplasty 3 (3.4)

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is then brought back through the lateral portion ofthe right platysma approximately 1 cm apart fromthe entrance of the sutures (Fig. 1, second row, left)and tied to tack the left platysma flap under the rightplatysma (Fig. 1, second row, right). This suture isrepeated in two or at most three sites in the samevertical row (Fig. 1, third row, left). Next, the freeborder of the right platysma is pulled over the leftplatysma by passing a suture near the free border ofthe right platysma (Fig. 1, third row, right), which isthen passed through the left platysma approximately

3 cm laterally (Fig. 1, below, left) and tied (Fig. 1, below,center). Two or three sutures will serve the purpose(Fig. 1, below, right). This technique creates an areaof platysma flap overlap (vest-over-pants), avoidingcentral roll commonly inherent in the repeated cen-tral plication. At no point does the repair extendcaudal to the hyoid bone. The senior author doesnot find partial transection of the medial borders ofthe platysma necessary. Although he has transectedthe platysma in its entire width as far caudally aspossible, the senior author has avoided this part of

Fig. 1. (Above, left) A 4-0 Mersilene suture is passed through the lateral portion of the right platysma approximately 3cm from the posterior border of the symphysis and, on average, 3 cm from the midline depending on the laxity of theplatysma muscle. (Above, right) The suture is passed through the medial border of the left platysma. (Second row, left)The suture is brought back through the lateral portion of the right platysma about 1 cm apart from the entrance of thesutures. (Second row, right) The suture is tied to tack the left platysma flap under the right platysma. (Third row, left) Thissuture is repeated in two or at most three sites in the same vertical row. (Third row, right) The free border of the rightplatysma is pulled over the left platysma by passing a suture near the free border of the right platysma. (Below, left) Thesuture is passed through the left platysma approximately 3 cm laterally. (Below, center) The suture is tied. (Below, right)Two or three sutures are used to complete the repair.

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the technique since the completion of the study. Thesurgical field is irrigated with saline containing an-tibiotic. A drain is placed under the flap and broughtout through the postauricular area on one side foran isolated submental lipectomy and both sides if theprocedure is being performed in conjunction withrhytidectomy. The submental incision is repairedusing 6-0 Monocryl and 6-0 fast absorbable catgut.

Statistical AnalysisThe data were analyzed using SPSS software ver-

sion 15 (SPSS, Inc., Chicago, Ill.). Quantitative dataare reported as mean � SD. Qualitative data arereported as frequency and percentage. A Wilcoxonsigned ranks test was used when comparing preop-erative and postoperative data of qualitative vari-ables. A value of p � 0.05 was considered significant.

Fig. 2. Patient before (left) and 1 year after (right) platysmarrhaphy and facial rhytidec-tomy (frontal and profile views).

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RESULTSThe mean patient age was 57.56 � 8.71 years

(range, 30 to 76 years). There were 76 women(86.4 percent) and 12 men (13.6 percent). Theaverage follow-up was 28.8 � 20.35 months.

Fifteen patients (17 percent) had no pla-tysma bands preoperatively, whereas 73 patients(83 percent) had prominent platysma bandspreoperatively (Figs. 2 through 5). Fifteen pa-tients who did not exhibit platysma bands still

underwent the vest-over-pants technique toavoid the visibility of the platysma borders fol-lowing significant submental contouring, whichwould have unmasked otherwise hidden plat-ysma bands. No one had residual bands postop-eratively (p � 0.001). Fifteen patients (17 percent)underwent caudal transection of the platysma. Therewas no statistically significant difference in the resultswhen the platysma was divided completely caudallyversus when the platysma left intact. Although there

Fig. 3. Patient before (left) and 11 months after (right) platysmarrhaphy and facial rhyt-idectomy (frontal and profile views).

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were submental flaws such as rare submentaldepression, none could be attributed to the plat-ysmarrhaphy.

DISCUSSIONA variety of factors can disturb neck congru-

ity. Redundant skin, platysmal bands and excessfat in the subplatysmal and supraplatysmalplanes, prominent anterior belly of the digastricmuscles, and hypertrophic or ptotic submaxil-

lary glands can commonly contribute to a dis-pleasing neck. A vast number of surgical andnonsurgical techniques have been introducedto deal with platysma bands. Botulinum toxintype A is one of the modalities used to eliminateplatysmal bands.

De Castro defined three anatomical patternsof platysma muscles.2 The knowledge and under-standing of the behavior of medial fibers of theplatysma as a result of aging is essential for plan-

Fig. 4. Patient before (left) and 18 months after (right) a rhytidectomy and platys-marrhaphy (frontal and profile views).

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ning the surgical procedures. McKinney classi-fied medial platysmal bands into four differentgrades.3 Surgical procedures for platysmal bands(platysmaplasty) have included excision and im-brication or plication of the muscle, either ante-riorly or by lateral elevation, excision of medialmargins, lateral platysmal plication to the sterno-cleidomastoid fascia,4–6 and midline platysmamuscular overlap in a double-breasted fashionthrough a lateral suture suspension technique.7

Guyuron has shown the importance of the hyoidbone and the attached muscles in a balanced neck.Transection of these muscles at their attachmentimproves neck contour.8

The senior author places the submental in-cision anterior to the submental crease. Thisprovides good exposure for lipectomy, muscleplication, and even removal of submandibularglands, and releases the bands creating the sub-mental crease.

Fig. 5. Patient before (left) and 1 year after (right) a rhytidectomy, platysmarrhaphy,ptosis correction, and full face laser resurfacing (frontal and profile views).

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Techniques for direct access of the platysma andimbrication have been described since the 1970s.These methods, however, have their shortcomingsand often produce recurrent paramedian musclebands, visible submandibular gland bulges, and var-ious contour irregularities. The corset platysma-plasty was developed by Feldman6 to avoid thosepostoperative imperfections. This technique couldresult in a palpable central neck roll. The seniorauthor has been using the vest-over-pants techniquesince 1983 in an attempt to redistribute the redun-dant platysma bands over a larger area to minimizethe palpability and to augment the stability. As isdemonstrated in this article by the independent re-viewer, in 100 percent of the patients, this techniquehas provided complete elimination of the bands. Asa matter of fact, during the 26-year experience withthis technique, no patient has undergone a second-ary platysma procedure for repair of the platysmabands, even though many have undergone second-and even third-generation face lifts. However, in allof these second- and third-generation rejuvenationpatients, there was some neck skin laxity that wascorrected with a facial rhytidectomy.

Del Campo combined passing a suture with“hammock platysmaplasty” in which the platysmamuscles are overlapped in a double-breasted fash-ion in the midneck through a minimal submentalincision and two retroauricular incisions.7 He in-troduced the single overlapping for grade I andgrade II bands and double overlapping for gradeIII and grade IV deformities.

Platysma has also been transected to eliminatethe platysma bands. The senior author has notfound this technique helpful, and there was nostatistical difference between those who had tran-section of the platysma and those who did not, inrelation to the platysma band visibility.

On patients who have severely obtuse necks,one of the major contributing factors is a prom-inent anterior belly of the digastric muscle. Themuscle bulk can be palpated as an extra roll of softtissue oriented laterocaudally. These patients alsohave excessive fat between the digastrics which, ifremoved without reduction of the digastric vol-ume, will results in submental hollowing, espe-cially while the patient swallows. Although re-moval of these muscles, subplatysmal fat,supraplatysmal fat, submaxillary glands, and con-touring of the submandibular region each con-tribute to the cervicomental definition, none re-duces the visibility of the platysma bands.

With senescence, there is submandibular sali-vary gland hypertrophy and/or gland ptosis. Thiscontributes to submandibular fullness and an ill-

defined mandibular border. Although gland prom-inence may be lessened by platysmarrhaphy, it maybe unmasked by submental lipectomy. Platys-marrhaphy and superficial musculoaponeurotic sys-tem–platysma repair often improves the gland po-sition. The senior author has suspended the glandwith a basket technique and Mitek anchor (DePuyMitek, Inc., Raynham, Mass.).9 He may also partiallyor totally excise the gland, depending on the case.

CONCLUSIONSThe neck dysmorphology can be the conse-

quence of excess skin, excess subplatysmal or supra-platysmal fat, prominent platysma bands, protrud-ing anterior belly of the digastric muscles, ptotic orhypertrophic submaxillary glands, or horizontal mi-crogenia. An optimal outcome can only be attainedby dealing with all of these flaws, when they coexist.In this article, the senior author’s 26-year experiencein correcting one of these imperfections is reported.There are not many techniques that do not changein 26 years, especially in the hands of those who areconstantly striving for improvement of results, unlessthe technique is delivering the intended objectivesfully and consistently. In the view of the authors, thisis a sensible technique that distributes the redun-dant platysma over a larger surface area rather thangathering in the center, and provides enduring re-sults by having multiple fixation points that providea secure repair.

Bahman Guyuron, M.D.29017 Cedar Road

Cleveland (Lyndhurst), Ohio 44124bguyuron@aol.com

PATIENT CONSENTPatients provided written consent for the use of their

images.

REFERENCES1. Ellenbogen R, Karlin JV. Visual criteria for success in restoring

the youthful neck. Plast Reconstr Surg. 1980;66:826–837.2. de Castro C. The anatomy of the platysma muscle. Plast Re-

constr Surg. 1980;66:680–683.3. McKinney P. Management of platysmal bands. Plast Reconstr

Surg. 2002;110:982–984.4. Knize DM. Limited incision submental lipectomy and platys-

maplasty. Plast Reconstr Surg. 1998;101:473–481.5. Rohrich RJ, Rios JL, Smith PD, Gutowski KA. Neck rejuvena-

tion revisited. Plast Reconstr Surg. 2006;118:1251–1263.6. Feldman J. Corset platysmaplasty. Plast Reconstr Surg. 1990;85:

333–343.7. del Campo AF. Midline platysma muscular overlap for neck

restoration. Plast Reconstr Surg. 1998;102:1710–1714.8. Guyuron B. Problem neck, hyoid bone, and submental myot-

omy. Plast Reconstr Surg. 1992;90:830–837; discussion 838–840.9. Guyuron B, Jackowe D, Iamphongsai S. Basket submandibular

gland suspension. Plast Reconstr Surg. 2008;122:938–943.

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