Submental liposuction should be limited to the area bordered by
the mandible. The marginal mandibular nerve is superficial in the
area of the angle of the mandible, and liposuction should be avoided
in this region. If the submental fat has been properly marked preop-
eratively, liposuction need not extend outside this area.
When significant submental fat is present, direct lipectomy is indi-
cated. The 2.5 cm incision allows direct visualization of the fat and even-
tually the edges of the platysmal muscle. A subcutaneous dissection is
performed with facelift scissors in the previously marked submental area.
Approximately 5 mm of subcutaneous fat is left attached to the skin flap,
which helps prevent unusual adherence of the skin to the underlying tis-
sue during healing. A small (0.5 inch) lighted retractor aids in visuali-
zation and obtaining hemostasis. Preplatysmal fat is removed with the
scissors. The edges of the platysma muscle can be visualized and pli-
cated if significant platysmal bands are present (Fig. 4-3). Marking the
bands on the skin surface preoperatively helps locate the medial edges
of the muscle during dissection. The medial edges of the platysma are
plicated with multiple 4-0 permanent sutures. The skin in this area is
closed with a running 6-0 nylon suture. No skin excision is performed.
Once neck repair is complete, the facial incision can be performed.
This incision is made with a Bard-Parker No. 15 blade and is kept par-
allel with the hair follicles to avoid hair loss. In the temporal area the
dissection can be performed using the back of a blade handle. The han-
dle is pushed firmly in a plane just under the skin. Blunt dissection
avoids damaging the hair follicles, and it stays superficial to the frontal
branch of the facial nerve. The facial nerve is quite superficial in this
area, running within the superficial temporalis fascia. This subcutaneous
dissection terminates halfway between the ear and the lateral canthus.
Anterior to the ear the skin is tightly adherent to the underlying
tissue, making dissection difficult for the first several centimeters. A
No. 15 blade is useful for this initial portion of the dissection. A facelift
scissors is then used to complete an extremely superficial dissection.
Countertraction with a double skin hook simplifies the dissection and
leaves the underlying SMAS intact. Depending on the SMAS tech-
nique employed, this dissection creates a skin flap 3–8 cm in length.
The retroauricular portion of the incision is often started with the
No. 15 blade as well. The skin overlying the mastoid process is adher-
ent to the underlying tissue. Once the dissection becomes easier, a facelift
scissors can be employed. As the dissection proceeds inferiorly in the
neck, it is important to maintain a superficial dissection plane between
the subcutaneous tissue and the superficial musculature. The great au-
ricular nerve becomes extremely superficial as it crosses the body of the
48 Rhytidectomy Surgery