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. 2021 Dec 3;31(3):275–286. doi: 10.1177/22925503211042868

Comparing Lateral Rhytidectomy With and Without Neck Suture Suspension

Comparaison de la rhytidectomie latérale avec et sans suspension de la suture du cou

Manoj T Abraham 1, Jaclyn A Klimczak 1,✉, Minali Abraham-Aggarwal 2
PMCID: PMC10467435  PMID: 37654534

Abstract

Background: Characteristic aesthetic changes of the aging neck include skin laxity and rhytid formation, submental fat deposition, plastysmal banding, and ptosis of underlying structures that lead to the development of an obtuse cervicomental angle (CMA). Cervical rejuvenation techniques that aim to restore the CMA are widely discussed in the literature, and share variable outcomes. The aim of this study is to compare the restoration of the CMA in patients undergoing the addition of midline platysmal plication using a modified Giampapa stitch with absorbable PDS suture, to those patients undergoing standard deep plane lateral rhytidectomy alone. Methods: A retrospective cohort study was performed by a single surgeon in a private facial plastics practice. 264 patients undergoing rhytidectomy were included in the study. Pre and postoperative measurement differences in CMA degree and depth were compared in patients undergoing only traditional deep plane lateral rhytidectomy (TDPLR) in isolation, with those who also had modified suture suspension and platysma plication (MSSPP). The primary outcome in the study was the change in the degree of the CMA taken from standardized preoperative and postoperative surgical photos in the Frankfort profile view. Secondary outcomes include the change in the depth of the CMA as determined by the hyomental distance between study and control groups. Results: A total of 264 patients were identified who met the study criteria. A total of 134 (123 female; 11 male; average age, 62.66 ± 8.19) underwent TDPLR with MSSPP, and 130 (127 female; 3 male; average age, 63.09 ± 7.75) underwent TDPLR alone. All patients in the study underwent preoperative photographic evaluation in Frankfurt profile view and the same postoperative photographic evaluation at an average of 436.56 days (14.4 months) after surgery. Patients in the cohort study group were found to have a statistically significant increase in the depth of the CMA by an average of 13.9 degrees ± 6.26 and increase in the hyomental distance of 1.38 cm ± 0.87, compared to the control group who underwent traditional lateral rhytidectomy with an average CMA change of 6.87 degrees ± 6.7 (P = .00146) and hyomental distance increase of 0.75 ± 0.68 (P = .00031), respectively. Statistical significance was taken at P < .05. Conclusions: The results from this study indicate that the addition of a relatively minimally invasive approach to neck rejuvenation using a modified Giampapa stitch with absorbable PDS suture is helpful in restoring the CMA in an aging neck.

Keywords: facelift, rhytidectomy, neck lift, cervicomental angle, hyomental length

Introduction

Aesthetic rejuvenation of the aging neck has posed a challenge for plastic surgeons with a number of different techniques developed with or without rhytidectomy over the years. In addition to the natural aging process which increases skin laxity, submental fat deposition, and platysmal banding, inherent anatomical constraints such as the projection of the mandible, ptotic submandibular glands, low-lying hyoid, and surrounding musculature can lead to surgical challenges in obtaining a successful aesthetic result.1,2 The Dedo classification was developed to stratify patients by these considerations in order to determine the “ideal candidate” for cosmetic neck rejuvenation surgery. A successful result in recreating the neck and jawline is largely created by redefining the CMA.3,4

Increase in the CMA which normally lies between 105 and 120 degrees is one of the first signs of an aging neck. The CMA has been used in addition to the hyomental distance as objective measurements for determining successful cervical rejuvenation surgery. 5 Naini et al described the importance of the CMA on perceived attractiveness among lay and clinician groups, with the majority agreeing on an angle between 90°-105° deemed most attractive, whereas angles up to 120° were less unattractive. 6 Recreating a youthful neck has been described in the literature for generations with surgical enhancements focusing largely on redraping the midline platysma and addressing the need for excision of submental fat.1,7 In 1995, Giampapa et al described a neck lift technique to be performed alone or in conjunction with a facelift to address the obtuse CMA, blunted jawline, jowling, and submental adipose. This suture suspension platysmoplasty is created through interlocking two horizontal mattress sutures through the midline plastysma at the level of the hyoid using permanent polypropylene sutures. The sutures are then suspended under the mandible through a subcutaneous tunnel to their anchor point on the mastoid fascia, creating an internal vector. 8

Our single-center retrospective cohort study looks to compare the change in CMA and hyomental distance between patients undergoing TDPLR with those undergoing TDPLR with a modified Giampapa stitch. This redefined technique uses absorbable PDS suture, midline corset plication of the platysma, and additional anchor points under the angle of the mandible, creating a more defined jawline and CMA through soft tissue repositioning. Using objective measurements that include the degree of change in the CM and change in hyomental length, we hypothesize that our enhanced approach will create a more defined CMA compared with TDPLR alone.

Materials and Methods

A retrospective cohort study was performed by a single surgeon in a private facial plastics practice from May 2010 to January 2021. Institutional review board approval was granted by New York Medical College. Age, gender, operative reports, and patient photographs were analyzed. Patients over the age of 18 were stratified into two cohorts that met our inclusion criteria: those who underwent TDPLR (n = 130) or those who underwent TDPLR with MSSPP (n = 134). Exclusion criteria included those with incomplete medical records and/or photographs, those lost to follow-up, and patients undergoing alternate rhytidectomy procedures. Standard pre and postoperative surgical photographs were taken in traditional 5-point views to include right and left profile, right and left oblique, and frontal. Profile views in the standard Frankfort horizontal position were used to study the CMA comparison of the two techniques. All photographs were taken at a standard camera distance from the subject, and a conversion factor was used to allow measurements taken on digitized photographs to be accurately converted to the actual measurements. The postoperative follow-up photographs were taken at an average follow-up time of 436.56 days (14.4 months) to allow for adequate wound healing and determine the longevity of results. CMA was measured from the horizontal plane of the submental region with the vertical plane of the neck and measured in degrees. Hyomental distance was calculated as the distance from the menton to the skin overlying the hyoid at the base of the CMA preoperatively. Surgical correction of the aging neck in both the control and study groups aims to lift the CMA to a new desirable position. This redefined position at the base of the new CMA was used for the measurement of postoperative hyomental distance. The accessors were not involved with the surgical procedures and were blinded to the surgical technique used.

Surgical Technique

The depth of the restored CMA is determined at the midline by having the patient gently flex the neck forward and using the surgeon's hands to lift the sagging neck tissues laterally and superiorly—this natural breakpoint is typically at or above the level of the hyoid bone (Figure 1). Local anesthesia and tumescent solution are infiltrated, and lipocontouring is completed in a standard fashion (Figure 2). No attempt is made to access or contour deep neck contents. The anterior platysmal bands are identified and corset plication is carried out from the submentum to the hyoid.

Figure 1.

Figure 1.

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Preoperative markings and incision planning.

Figure 2.

Figure 2.

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Lipocontouring down to the level of the CMA.

The Giampapa sutures are then placed in the following fashion. Using a full length 3 to 0 PDS suture, a vertical bite is taken through the anterior border of the platysma on one side at the new CMA as determined by the preoperative markings. With a second full length 3 to 0 PDS suture, a similar bite is taken through the anterior border of the platysma on the opposite side, and this second suture is interlocked with the first (Figure 3). The sutures are labeled left and right so they can be identified.

Figure 3.

Figure 3.

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Corset platysma plication with placement of an interlocking suture suspension at the level of the new CMA.

TDPLR is then carried out with standard lateral rhytidectomy incisions, followed by subcutaneous flap elevation and deep plane superficial musculoaponeurotic system (SMAS) and platysma dissection with release of the cervical retaining ligaments. 9 The SMAS is suspended superiorly, divided posterior to the angle of the mandible and the platysma resuspended laterally to the mastoid periosteum using several 3 to 0 PDS sutures. MSSPP is then completed by delivering each of the labeled sutures under the neck skin flaps to the opposite side (Figure 4). To anchor the sutures under the mandible, the threads of each suture are passed in parallel fashion superficially through the platysma under the angle of the mandible and then secured to the mastoid periosteum (Figure 5). Each side suture is passed identically, locking in the midline with the platysmal sling to lift and restore the CMA. TDPLR is completed with the removal of excess skin and tension-free closure of incision sites.

Figure 4.

Figure 4.

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Each suture thread is tunneled under the skin flaps and anchored at the level of the angle of the mandible to create a 3-point suspension fixation.

Figure 5.

Figure 5.

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The threads of each suture are passed in parallel fashion and secured to the mastoid periosteum.

Statistical Analysis

Statistical analysis was performed using Microsoft Excel Version 16.22, 2019. Demographics were compared between the two groups. Continuous variables were measured using a multivariate test of means. Categorical variables were evaluated via Pearson Chi-square tests. The change in CMA and hyomental length were compared using standard two sample independent t-tests. Statistical significance was defined as P < .05.

Results

A total of 276 medical charts of patients undergoing rhytidectomy were reviewed from May 2010 to January 2021, and 264 met inclusion criteria. The control group consisted of 130 patients (127 female, 3 male) with a mean age of 63.1 (range, 47–75) years. The study group had 134 patients (123 female, 11 male) with a mean age of 62.7 (range, 43–78). The average postoperative follow-up was 436.56 days (14.4 months). The longest follow-up in the study group was 124 months (11.3 years) (Figure 6). No significant difference was found between age (P = .41) and gender (P = .052) (Table 1). Preoperative CMA and hyomental distance were calculated between both groups, with no significant difference found (P = .97 and P = .78). Patients were stratified into either the control or the study group at the preoperative evaluation where a collaborative decision was made between the surgeon and patient regarding the surgical approach to best achieve the patient's desired goals. We noted more men in the MSSPP group compared to the TDPLR alone group as they more often requested comprehensive correction.

Figure 6.

Figure 6.

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Cervicomental Angle (CMA) measurements before, 21 months (1.75 years), and 124 months (11.33 years) after Traditional Deep Plane Lateral Rhytidectomy with Modified Suture Suspension and Platysma Plication (TDPLR + MSSPP).

Table 1.

Demographics.

TDPLR Mean (SD) MSSPP Mean (SD) P-value
Age 63.1 62.7 .41
Gender Male-3
Female-127		 Male—11
Female—123		 .052
Preoperative CM angle (degrees) 136.97 (12.5) 140.37 (15.9) .97
Preoperative hyomental distance (cm) 3.42 (1.17) 3.14 (1.09) .78
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*P value is significant at .05.

Patients in the control group who underwent TDPLR had an average of 6.87 degrees (SD ± 6.7) in CMA improvement and a 0.75 cm (SD ± 0.68) change in hyomental length. Patients in the study group had an average of 13.9 degrees (SD ± 6.26) in CMA improvement and a 1.38 centimeter (SD ± 0.87) change in hyomental length (Table 2). The difference in CMA improvement was shown to be significant (P = .00001) in patients undergoing rhytidectomy with MSSPP. In addition, the change in hyomental length was meaningfully improved compared to the control group (P = .00001), with a more posterior displacement and aesthetically successful result (Figure 7a and b). No significant complications were noted.

Table 2.

Change in Cervicomental Angle and Hyomental Distance Between Control and Study Groups.

Lateral rhytidectomy mean (SD) Modified suture suspension and platysma plication mean (SD) P-value
Preoperative CM angle 136.97 (12.5) 140.37 (15.9)
Postoperative CM angle 129.9 (12.5) 125.82 (16.2)
Change in CM angle 6.87 (6.7) 13.9 (6.26) .00001*
Preoperative hyomental distance 3.42 (1.17) 3.14 (1.09)
Postoperative hyomental distance 4.18 (1.16) 4.52 (1.03)
Change in hyomental distance 0.75 (0.68) 1.38 (0.87) .0001*
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*P value is significant at .05.

Figure 7.

Figure 7.

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Before and After a TDPLR and after a TDPLR with Modified Suture Suspension and Platysma Plication (TDPLR + MSSPP).

Discussion

Cervical rejuvenation surgical procedures have been discussed in the literature for over a century with the goal of restoring the youthful contour of the neck. Multiple advances in techniques have been introduced, with the goal of achieving improved results and less invasive approaches. The focus of neck rejuvenation, which was described by Ellenbogen and Karlin and still widely used today, is based on six visual criteria in the evaluation of the facial profile, with the ultimate goal of restoration of the CMA. These criteria included a sub-hyoid depression, a distinct inferior mandibular border, a visible thyroid cartilage bulge and anterior sternocleidomastoid border, and a sternocleidomastoid-submental line angle of 90 degrees. 4 Age-related blunting of these characteristics, therefore, necessitates a comprehensive surgical approach to reverse these changes. Our results indicate that in comparison to the control group that underwent only lateral rhytidectomy, the addition of corset platysma plication and our suture suspension significantly improves the CMA and hyomental length.

Both traditional lateral rhytidectomy and our modified Giampapa platysmoplasty technique employ some overlapping steps. Giampapa et al originally described a technique to improve the CMA through a suture suspension platysmoplasty. In addition to standard submental and submandibular lipocontouring via a small linear submental incision, Giampapa's technique includes platysmal resection and tunneling of nonabsorbable interlocking polypropylene sutures from the midline platysma under the inferior mandible border before securing to the mastoid fascia on each side. 8 Although CMA depth can be limited due to the patient's anatomy, this technique suspends the midline platysma muscle into a position at or superior to the hyoid, creating a so-called artificial ligament that can be adjusted based on the tension applied to give the desired depth.

Our modified Giampapa platysmoplasty technique uses long-lasting absorbable PDS suture material to replace the polypropylene sutures, allowing for tissue rearrangement without the effects of suture reactivity. In addition, the platymsal bands are released down to the level of the hyoid and a midline corset platysma plication is routinely performed. The corset creates a tight sling under the mandible, allowing resuspension of the submental contents, including subplatysmal fat, submandibular glands, and muscles including the digastrics, without the contents prolapsing over the suspension sutures, much as a belly would prolapse over a tightened belt without a corset. Finally, we have added a second stabilization point under the angle of the mandible to prevent superior migration of the suspension sutures, which provides the additional benefit of further defining the gonial angle. Both arms of the suspension suture are passed superficially through the platysma under the angle of the mandible. Therefore, the restoration of the CMA through the use of this modified artificial ligament does not start at the hyoid and travel in a straight line to the mastoid periosteum as originally described by Giampapa. The addition of this stabilization point under the angle of the mandible for both suture threads on both sides allows the trajectory to break in its natural fashion at the level of the angle of the mandible before traveling upward to its anchored position at the mastoid periosteum (Figure 2). Therefore, we do not rely solely on 2-point artificial ligament suspension, but by incorporating midline corset platysma plication and additional fixation points, more comprehensive tissue rearrangement and repositioning is achieved.

Suspension techniques to elevate soft tissue of the midface, brow, and neck as seen with Giampapa, either independently or combined with other techniques, are not new and have been described for many decades in the plastic surgery literature. The phenomenon of suture migration through the soft tissue fixation points that lead to loss of elevation and repositioning, also known as “cheese-wiring,” was a commonly reported problem with suspension techniques with 1 or 2-point suture fixation. When tissue is under tension, the body's natural response is to recruit collagen, elastin, and ground substance allowing the distance between fixation points to lengthen and ultimately reduce the tension. Similar to the mechanism of tissue expansion, this recruitment leads to relaxation of the surrounding soft tissue and therefore loss of that desired suspension.10–12 Another complication of tissue under tension at 1-or 2-point fixation is ripping or tearing of the tissues at the anchor points, which is more likely once the patient initiates natural movements after surgery. Therefore, the lack of long-term sustainability is a downfall of suspension techniques used in isolation. Tiryaki et al looked at the potential for their loop-suspension technique in percutaneous neck lifting which relied on tissue re-draping and remodeling rather than suspension alone to achieve reliable cosmetic results. 13 Our technique similarly implements this theory of tissue remodeling with corset platysma plication and skin re-draping in addition to platysma suture suspension with our additional stabilization points below the angle of the mandible to take tension off the soft tissue fixation points at the CMA and mastoid periosteum.

The choice of buried suture material has been long debated in the literature as these sutures if they are placed under the skin may trigger a foreign body reaction with inflammation-causing erythema of the overlying skin and can eventually lead to suture extrusion. A large amount of data on suture material and suspension techniques are specifically described in the orthopedic literature in the setting of ligament and tendon repairs. The shift to the use of absorbable suture material such as PDS has been widely implemented due to the consistent and reliable repair in the setting of fewer complications related to the suture such as wound infection and reaction.14,15 Parara et al compared suture materials polydioxanone, polypropylene blue, polyamide 6, metallic clips, and polyglactin based on digital color analysis to determine local skin reaction in the form of erythema. They found polydioxanone PDS II suture was significantly less irritating and also led to better satisfaction scores among short-term aesthetic results. Overall, in comparison to their nonabsorbable counterparts, absorbable sutures were found to cause markedly less skin erythema and reactivity. 16 Local stitch reactions such as extrusion through the skin or “spitting” of the stitch, and formation of micro-abscesses are more common with nonabsorbable material. Although rare, there have been reported adverse reactions to polypropylene material that were improved upon suture removal.17–20 Levin et al described a case of a patient who underwent surgical neck rejuvenation 5 years prior with Mersilene sutures who developed bilateral tender, erythematous submandibular nodules later diagnosed as suture granulomas. 21 Suture granulomas occur as a reaction to suture material and can persist for many decades after the initial surgery and can easily be mistaken as an infection or new mass. While many types of sutures can lead to granuloma formation, synthetic nonabsorbable braided materials are the most reactive. 22

We postulate that with our absorbable suture suspension procedure, it is not necessary for these sutures to hold permanently, as we rely on tissue repositioning and re-draping at multiple levels including the platysma muscle and overlying skin to maintain the lift. This concept has been well studied and replicated over the years with histologic studies demonstrating the increase in collagen deposition and connective tissue formation around long-lasting absorbable sutures. As the suture degrades through hydrolysis, hyaline fibrous tissue composed of collagen and elastin fibers continues to undergo remodeling thereby allowing the repositioned tissues to retain their strength and resiliency in the newly oriented position. Absorbable suture material also allows for the tissue to retain its natural pliability and integrity thereby creating a more natural appearance.

PDS suture is often the workhorse of absorbable suture material because of its ability to provide wound support for 60 days, and its delayed resorption of 6–8 months, compared with its cousins vicryl, chromic, and monocryl. 23 In procedures such as rhinoplasty where permanent sutures are often thought to be necessary to achieve permanency of cartilage contour, it has been established that PDS sutures can achieve an equally lasting and favorable result without the risk of suture reactions. 24 Allowing multiple fixation points ensure tissue reorganization into the newly oriented position while sharing tension between multiple points. The use of a robust absorbable suture with delayed absorption such as PDS allows for the natural process of fibrosis to occur more completely around the suture fixation and suspension points. This has the potential for longer-lasting results, with the added benefit of a less reactive suture material naturally absorbed by the body.

Closed approaches to neck rejuvenation have gained popularity over the years as attractive alternatives to patients who seek subtle improvements to the aging neck without undergoing significant anesthesia or a more invasive procedure and the attendant healing time. 25 The Food and Drug Administration approved nonabsorbable barbed sutures for these so-called “thread lifts” in 2004.25,26 Because of many reported complications with the use of these permanent sutures, FDA approval was withdrawn only 3 years later. More recently, absorbable suture material for thread lifting has been introduced with improved results and less suture- related complications. 27 Manufacturing companies have specifically begun to produce many types of PDS absorbable threads because of the lower risk profile. Histopathological studies looking at absorbable PDS sutures for thread lifting have found that these sutures induce a dermal and subcutaneous foreign body reaction that initiates lymphocytes infiltration, collagen deposition, and fibrosis thereby leading to a skin tightening effect through contracture repositioning and re-draping of the surrounding soft tissue.28–30 However, by definition, because of the closed nature of these thread techniques, since there is no release and rearrangement of the tissues and thereby less ability to fix and heal in multiple tissue planes, the degree of improvement and longevity of result is expected to be less compared to our technique. Despite the desirability of less invasive techniques, many studies have found only short-term improvement with thread lifts.31–33

On the opposite end of the spectrum, there are more aggressive techniques for neck rejuvenation that have been popularized to address subplatysmal structures, such as the digastric muscles, mylohyoid muscle, hyoid, subplatysmal fat, and bilateral submandibular glands. 34 The rationale for these invasive procedures is that lipocontouring of the submentum may unmask but not correct deeper anatomic structures contributing to the aging neck. 35 These deeper structures such as the submandibular glands and anterior belly of the digastric muscles are often resected or partially resected to recontour the CMA and inferior border of the mandible. Access to these structures may include a larger submental incision for lateral exposure and are not without an increased risk to underlying neurovascular structures. Potential risks of submandibular gland resection include bleeding due to exposure of the facial artery and vein, nerve injury (lingual nerve, hypoglossal nerve, mylohyoid nerve, and marginal mandibular branch of the facial nerve), xerostomia, sialocele, and hollowing of the submandibular triangle. 36 Due to a deeper resection and exposure of these major vascular contributions, the risk of bleeding and postoperative hematoma with possible airway compromise is increased and may warrant overnight hospital observation. Sialoceles that develop after submandibular gland excision may require more extensive postoperative care such as percutaneous drainage or postoperative botulinum toxin injections until resolution.36,37 In addition to the increased risks, more extensive surgery requires longer operating time and recovery. With our technique with corset plication of the platysma and Giampapa suture suspension, a sling is created to lift the subplatysmal contents, obviating the need for more invasive deeper dissection and thereby reducing the risk and need for superior surgical skill.

Although our technique employs liposuction to remove some of the tissue in the submental area, the majority of correction is achieved by tissue repositioning to a more youthful orientation. Initially post procedure, some patients report a temporary garroting or strangulation sensation, but this invariably resolves after several weeks. No patients reported any long-term problems with dysphagia, odynophagia, or obstructive sleep apnea.

Anecdotally, the senior author has noted some recurrence of platysma bands and skin laxity over time, although not to the degree described by Pelle-Ceravolo who found a 50% recurrence of platysma bands and loose skin at 12 months after surgery. 38 Ancillary treatments with neuromodulator, skin resurfacing, and technologies that regenerate collagen are useful to optimize and maintain results.

Our study aimed to incorporate the vast amount of literature on absorbable suture material, using PDS as well as tissue repositioning and additional fixation points in our modification of the Giampapa suspension ligament technique to redefine the CMA. In patients undergoing this modification, we found consistent improvements that were significantly more impressive in CMA degree of change and hyomental length improvement than patients who underwent traditional lateral rhytidectomy alone. Many techniques have been presented over the years to tackle the challenge of the obtuse CMA. Our modification is a simple, safe, and effective technique that can be incorporated with traditional lateral rhytidectomy procedures to achieve a greater degree of improvement in the CMA.

Limitations

Our study is limited by the sample size of patients and inability to formally randomize patients undergoing cosmetic facial plastic procedures. The decision to undergo TDPLR versus MSSPP or any other face and neck rejuvenation technique was based on preoperative consultation between the patient and surgeon to determine the best treatment plan for each individual patient, with considerations including but not limited to the patient’s anatomy and aging-related changes, as well as the patient's expectations in terms of affordability, healing time, and results. Although preoperative CMA and hyomental distance were not significantly different between groups, it is possible there was selection bias with patients with more difficult necks more likely to undergo MSSPP, making the more significant improvements seen in the study group with this technique even more relevant. We did not study if superficial neck liposuction or platysma plication in isolation would have provided the same degree of improvement. However, as the platysma and neck skin naturally drape over the hyoid, neither of these interventions is able to lift and set the CMA above the level of the hyoid in the same way as the artificial ligament created by the Giampapa sutures. Control and study populations were also largely female, unsurprisingly in this subset of patients undergoing neck rejuvenation surgery.

Conclusions

We looked to determine the difference in pre and postoperative CMA after traditional lateral rhytidectomy compared with rhytidectomy using a suspension platysmoplasty and absorbable modified Giampapa stitch. Our modification utilizes long-lasting absorbable PDS allowing inherent wound healing and tissue remodeling to occur and set in the lifted, rejuvenated position. Our technique incorporates two novel platysmal anchor points under the angle of the mandible to provide additional support for this Giampapa artificial ligament and prevents displacement of these sutures over the mandible. We verified that this modification to traditional lateral rhytidectomy produces a significantly more defined CMA and improved hyomental length necessary for achieving successful aesthetic results in neck rejuvenation. Patients had consistent and reproducible early results utilizing this less invasive technique for neck rejuvenation, making this a promising addition to traditional lateral rhytidectomy for the aging neck.

Footnotes

M.A and J.K contributed to the design and implementation of the research, to the analysis of the results and to the writing of the manuscript. MAA contributed to the extraction of research data and analysis.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD: Jaclyn Klimczak https://orcid.org/0000-0001-5559-6663

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