Response to: Platysma Hammock or Sling: Are They Different?

“La résistance au changement n’est que le refus de la croissance.”

—Alexander Ruperti

We appreciate the careful consideration Aston and Hanna have given to our work on our extended deep plane facelift technique with a novel platysma hammock flap.¹ Although we welcome the dialog and the historical perspective offered by the authors regarding the surgical manipulation and management of the platysma during face and neck lifting, we disagree with the conclusions at which they have arrived.

Aston and Hanna assert firstly that our extended deep plane facelift approach is simply a reincarnation of the “‘deep plane facelift,’ formerly the ‘composite facelift’.” We assume that they are referring to the “deep plane facelift”² and “composite facelift”³ described by Hamra. Although seemingly similar on the surface, the extended deep plane differs from these previously described techniques as we discussed in our description of the extended deep plane facelift.⁴ In contrast to our method, Hamra's deep plane facelift and composite technique do not elevate the sub–superficial musculoaponeurotic system (SMAS)/subplatysma plane below the angle of the mandible, but simply plicate the platysma below this level. Our technique “extends” the subSMAS/subplatysma dissection for 5 cm inferior to the angle of the mandible and medially from the sternocleidomastoid muscle (SCM) to the anterior aspect of the submandibular gland. This significant alteration of cervical dissection is one key difference between Hamra's deep plane facelift and our extended deep plane facelift.

We acknowledge that Skoog first described posterior detachment of the platysma from the SCM followed by the elevation of a composite skin-platysma flap, which was then secured to the mastoid periosteum.⁵ Interestingly, our extended deep plane technique for the first time married Hamra's and Skoog's approaches, connecting their respective deep dissections. Hamra did not elevate the platysma below the mandible. Skoog left an undetached mesentery of SMAS/platysma above the mandible separating their cheek and neck deep subfascial dissections; in his surgical description he states that the mandibular branch of the facial nerve is protected by elevating the platysma only below the level of the mandible, not above it. The unelevated areas in both Hamra’s and Skoog's techniques were undissected to avoid injury to the marginal branch of the facial nerve. They can be connected safely during dissection as the nerves exist in the deep fascia superior and inferior to the mandible. Dissecting superior to the mandible just deep to the SMAS in the cheek leaves the facial nerves undisturbed because they are within the deeper parotid-masseteric fascia. As the parotid-masseteric fascia is contiguous with the superficial layer of the deep cervical fascia, continuing the dissection inferiorly, under the platysma, ensures that the marginal mandibular and cervical branches of the facial nerve remain safely deep to the superficial layer of the deep cervical fascia. We have performed over 2500 extended deep plane facelifts since we started to perform this technique in 2008,⁶ with a temporary facial nerve injury rate of approximately 1% and no permanent facial nerve injuries. Furthermore, our extended deep plane technique differs from Skoog's as his subplatysmal dissection only extended for 1.5 to 2 cm below the mandibular line, whereas we develop a more extensive flap for greater platysma redraping that extends for 5 cm below the angle of the mandible.

Aston and Hanna assert that our platysma hammock and myotomy is “not novel but iterative,” and in response to this claim we double down on our initial assertion. All myotomies are not synonymous or created equal because they create different biomechanical effects depending upon their anatomic location, flap configuration, and vectoring. In fact, our high myotomy has not been described before and its location creates a flap that lends strength and support to the submandibular line and contents of the submandibular triangle. We hypothesize that other authors have not performed our high myotomy because of the dogma that one should not transect the platysma above a point 4 cm below the mandibular line in order to avoid injury to the marginal branch of the facial nerve. As described above, a properly elevated extended deep plane flap will leave all facial nerve branches safely within the deep cervical fascia and will not risk nerve injury.

Aston and Hanna described the historical evolution of the placement of platysma myotomies at different locations, which we believe have different effects on neck contour. Peterson,⁷ Connell,⁸ and Aston^9,10 described use of a low transverse myotomy that does not create a biomechanical effect at the level of the submandibular gland. In fact, the platysma can retract superiorly, as a “window shade” and create redundancy just below the mandible. Guerrero-Santos et al performed a 2-flap technique, elevating the platysma posteriorly from the SCM, with the platysma myotomy at the midpoint of the vertical length of the SCM, probably 3 to 4 cm below the mandibular line, with the superior and inferior flaps suspended in opposite directions.¹¹ Ceravolo et al performed a myotomy at a similar height to that used by Guerrero-Santos et al but with a composite flap elevating the platysma far anterior at a location at the midpoint of the mandibular body, placing it 3 to 4 cm anterior to the SCM (Figure 1).¹²

Figure 1.

Previously described platytsma myotomies compared to platysma hammock myotomies. (A) Peterson, Connell, Aston: low transverse myotomy. (B) Guerrero-Santos: 2-flap technique, elevating the platysma posteriorly from the SCM, with the platysma myotomy at the midpoint of the vertical length of the SCM, typically 3 to 4 cm below the mandibular line, with the superior and inferior flaps suspended in opposite directions. (C) Pelle-Ceravolo: a composite flap elevating the platysma at a location at the midpoint of the mandibular body placed 4 cm anterior to the SCM, with the platysma mytomy at the midpoint of the vertical length of the SCM, typically 3-4 cm below the mandibular line, with the superior and inferior flaps suspended in opposite directions. (D) Jacono: high myotomy just below the mandibular line after elevating the platysma for 5 cm inferior to the angle of the mandible and medially from the SCM to the anterior aspect of the submandibular gland. SCM, sternocleidomastoid muscle.

Aston and Hanna assert “the myotomy is concerningly high and is liable to produce palpable or visible edges.” Although a high myotomy may seem concerning on first glance, we believe it is actually aesthetically advantageous. Placing the myotomy below the submandibular line creates a concavity below the jawline which is a hallmark of a youthful transition from the mandible to the neck. We do not agree with the authors of this commentary that a “visible edge is demonstrated in lateral views of Figures 5 and 7” of our paper; we do not see this in the images at all. Low and midplatysma body platysma transection creates depressions along the areas of myotomy where a platysma deficit exists, and ridges above and below the myotomy. In fact, lower myotomies will create visible deformities in the midneck, especially in patients with thin skin, which can appear unsightly. In the senior author's experience with performing hundreds of low and midplatysma body full-width transections, the platysma would often “window shade” superiorly, creating a 2- to 3-cm gap between the cut platysma edges. Many patients developed concavities in the region of the myotomy that improved over time but never fully resolved. In his previous work Aston admits “Full width division of the platysma was overused during the early stages of platysma surgery” and “platysma transection after fat removal may produce an overoperated ‘popsicle on a stick’ appearance.”⁹

Aston and Hanna further assert that “the submandibular gland is neither lifted nor supported in the long term” with our platysma hammock technique. We have demonstrated in this study that the submandibular gland is supported and lifted long term at 18 months and have many examples of the effect lasting between 5 and 10 years (Figure 2). Further, this technique can be used to revise patients having a previous SMAS facelift with a low platysma transection that failed to create a tight contour and elevate the submandibular triangle contents (Figure 3). We believe this is due to the unique aspects of this platysma hammock flap. This lack of recurrence of platysmal banding and sustained improvement in submandibular gland ptosis is a result of the flap architecture. The myotomy places the medial extent of the myotomy under the submandibular gland fascia and along a line to the mastoid, resulting in a muscular flap with a tension bar in the submandibular region. This platysma flap acts as the floor that supports the contents of the submandibular triangle. A recent study using serial MRI has demonstrated that no significant difference in total gland volume or glandular height occurs with aging, emphasizing glandular descent over hypertrophy as the most important change with aging.¹³ This study isolated and measured the volume of the gland inferior to the mandible (IM) to characterize the portion of the submandibular gland (SMG) most clinically relevant and observed an increase in IM-SMG volume. We believe that this ptosis results from loss of fascial and platysma muscular support as age weakens these structures.

Figure 2.

(A-C) Preoperative, 1-year, and 7-year postoperative oblique views of a 53-year-old female patient after extended deep plane facelift and platysma hammock. (D-F) Preoperative, 1-year, and 7-year postoperative lateral views of the patient. The extended deep plane facelift platysma hammock flap has maintained the improvement in submandibular gland ptosis and platysma cording at 7 years.

Figure 3.

(A, C) Preoperative and (B, D) 1-year postoperative views of a 60-year-old female patient after undergoing an extended deep plane facelift and platysma hammock after a previous biplanar superficial musculoaponeurotic system facelift with low platysma transection performed elsewhere 18 months previously. Notice the how the platysma transection and platysma hammock created a defined submandibular contour, suspended the submandibular gland, and created significantly improved platysma redraping at 1 year.

Recent studies by Labbé et al help elucidate the power of the platysma hammock flap.¹⁴ They define the cervicomental angle suspensory (CMAS) ligament, a system of dense fibrous tissue on the deep surface of the platysma that extends along a line from the cervicomental angle to the mastoid. Aging creates laxity and redundancy in the CMAS ligament. The platysma hammock flap creates a flap centered around the CMAS ligament, and therefore redraping and suspending the flap engages the ligament, creating further durability of the flap repair (Figure 4). A natural effect of the tension bar, the platysma hammock supports the submandibular triangle, elevates ptotic submandibular glands, and creates a submandibular concavity below the mandibular line.

Figure 4.

Aging creates laxity and redundancy in the CMAS ligament. The platysma hammock flap creates a flap centered around the CMAS ligament, and therefore redraping and suspending the flap engages the ligament. (A) The heavy black line outlines where the platysma is elevated from the sternocleidomastoid muscle and the high platysma myotomy. (B) A natural effect of the tension bar, the platysma hammock with the durability of the CMAS ligament supports the submandibular triangle, elevates ptotic submandibular glands, and creates a submandibular concavity below the mandibular line. CMAS ligament, cervicomental angle suspensory ligament.

Finally, Aston and Hanna assert that “composite techniques which leave the skin, fat, and SMAS/platysma attached together do not allow for the most elegant facial rejuvenation” because they do not “allow independent manipulation of the skin and the underlying foundation—the SMAS and platysma” as is possible with biplanar SMAS techniques. This is a common claim that in deep plane facelift surgery, the vector of skin redraping must be in the same direction as deep tissue manipulation. In the biplanar SMAS approach, the SMAS is elevated more vertically and the skin more horizontally. The skin does not age in a horizontal gravitational plane, and the only reason for horizontal skin redraping in the SMAS approach is to avoid dealing with a dog ear in the superior aspect of a temporal hair-sparing facelift incision or to avoid elevating the temporal hair tuft if the incision is placed inside the temporal hair-bearing scalp. It is not because it serves a more rejuvenative effect; in fact, most would argue horizontal facial skin tightening tends to make the face appear more mask-like or tightened in an unnatural way.

The truth is that in deep plane surgery the vector of skin redraping can differ from the vector of the deep plane suspension because the skin can rotate about the axis of the fixation sutures placed in the SMAS. The subcutaneous skin flap is approximately 3 cm in length, lateral to the deep plane fixation. Our preference is to redrape the skin vector in a more vertical vector because its redundancy was created in a vertical plane through gravitational stress on the skin; however, it can be redraped either more horizontally or vertically compared to the deep plane vector, depending on the amount of redundancy and to prevent pleating along the temporal repair. Often this results in the majority of the skin being removed vertically in the temporal region. A significant concern of vertical skin redundancy excision is the creation of temporal bunching in the skin between the lateral orbit and the temporal hair tuft. Many fear skin elevation here because the temporal branch of the facial nerve exists in the region half the distance between the lateral canthus and tragus along the zygomatic arch, but the nerve is in the deeper tissues of the superficial temporal fascia; staying in the subcutaneous plane avoids such injury.

Again, we wish to thank the commentators for their thoughtful reading of our publication and the addition of important historical context. We believe that our description of the platysma hammock and accompanying myotomy represents a novel advancement in face and neck lift surgery as it leverages the resilience of the CMAS ligament to create a strong muscular flap that supports the contents of the submandibular triangle. To date, such a construct has not been described in the literature. As demonstrated in our published manuscript and by the figures herein, the platysma hammock creates aesthetically pleasing, stable long-term jawline and neck results.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.