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Development and Validation of a Clinical Assessment Tool for Platysmal

Banding in Cervicomental Aesthetics of the Female Neck

Article  in  Aesthetic surgery journal / the American Society for Aesthetic Plastic surgery · August 2015
DOI: 10.1093/asj/sju160 · Source: PubMed

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Facial Surgery

Aesthetic Surgery Journal

2015, Vol 35(6) NP141–NP146
Development and Validation of a Clinical © 2015 The American Society for
Aesthetic Plastic Surgery, Inc.
Assessment Tool for Platysmal Banding in Reprints and permission:
journals.permissions@oup.com

Cervicomental Aesthetics of the Female Neck DOI: 10.1093/asj/sju160

www.aestheticsurgeryjournal.com

Subhas Gupta, MD, CM, PhD, FRCSC, FACS; Nataliya Biskup, MD;
Gennaya Mattison, MD; and Amber Leis, MD

Abstract
Background: In facial aesthetics, grading systems are useful tools for planning aesthetic procedures. One key component of rejuvenation—the anterior
neck—has been relatively overlooked. In the 1980s, criteria were established for the appearance of a youthful neck. Considering the significant contribution
of the anterior neck to the aesthetics of the lower face, updated and more extensive clinical evaluation tools are critical to successful execution and mea-
surement of rejuvenation. A validated assessment scale has yet to be created for platysmal banding, one component of the anterior neck that significantly con-
tributes to the aesthetics.
Objectives: The purpose of this study was to establish a validated platysmal banding scale for clinical application.
Methods: Three-dimensional standardized photographs from over 100 volunteer patients of various ages and ethnicities were analyzed to develop a five-
point scale for platysmal banding. The scale was validated by a group of academic and nonacademic attending plastic surgeons as well as senior level plastic
surgery residents then analyzed through a two stage process to ensure both interrater and intrarater validity.
Results: We measured the Intraclass Correlation Coefficients (ICC) for the interrater reliability. ICCs ranged from moderate to excellent agreement.
Cronbach’s alpha, which represents intrarater reliability, was also calculated for the same sample with all results being good to excellent.
Conclusions: This study established a validated scale to assess the degree of platysmal banding in the female neck. This grading system has potential appli-
cation in the preprocedure planning for patients considering face and neck rejuvenation to address platysmal banding.

Accepted for publication December 19, 2014.

Grading systems often aid in the planning of aesthetic pro-
cedures and in the evaluation of outcomes. For evidence-
based practice, grading systems provide the ability to assess
new or adjusted techniques objectively. New innovations
and developments in the field of facial rejuvenation have
created an unmet need for assessment tools applicable to
both clinical use and evidence-based evaluation.
One key area of facial rejuvenation—the anterior neck—
has been frequently overlooked in the development of
grading and classification. Many of the limited publications
to date are from the 1980s, when the neck started to
become an area of focus in the literature of plastic surgery.
Dedo proposed a classification of the neck that focused spe-
cifically on cervical abnormalities. He suggested six classes
encompassing various characteristics of the abnormal
neck, including muscle accentuation as defined in Class
IV.1 In addition, Ellenbogen and Karlin established five sig-
nificant criteria for the appearance of a youthful neck.2 The
delineation of these criteria established a guideline for
outcome goals in the rejuvenation of the anterior neck;
however, the work did not focus on measuring the aesthet-
ic deformity in the region. Additional grading scales for
anterior neck deformities exist, including one for cervico-
mandibular angle variations3 as well as a four-category
classification of severity of platysmal banding.4 Though
helpful as general tools, these scales were not validated and
do not delineate the variability into a five-point scale. In the
intervening decades, numerous assessment tools, both
From the Department of Plastic Surgery, Loma Linda University School
of Medicine, Loma Linda, CA, USA.
Corresponding Author:
Dr Nataliya Biskup, Department of Plastic Surgery, Loma Linda
University School of Medicine, 11175 Campus Street, Suite 21126,
Loma Linda, CA 92354, USA.
E-mail: nataliya.biskup@gmail.com
NP142
validated and not, have been developed for assessing other
areas of the face. Beyond the previously mentioned works,
there are not many tools to aid the clinician in assessment
of the anterior cervical region.
One of the major components contributing to anterior
neck aesthetics is the degree of platysmal banding. To date,
however, no validated scales exist in plastic surgery litera-
ture that specifically addresses the variable severity of pla-
tysmal banding. The anterior neck contributes significantly
to the aesthetics of the lower face.5 In addition, clinical
evaluation tools are critical to successful planning and exe-
cution of rejuvenation. Therefore, we utilized advanced
imaging tools to meet this area of need about aesthetics and
planning. The purpose of this study was establish a clinical-
ly useful validated platysmal banding scale.
METHODS
Our study was approved by the Institutional Review
Board at the Loma Linda University Medical Center (Loma
Linda, CA) and conducted in accordance with the guide-
lines set forth in the Declaration of Helsinki. Utilizing the
3dMD system (Atlanta, GA), 3-dimensional standardized
photographs of the cervicomental region were collected
from female volunteer patients of various ages, ethnicities,
and body habitus from June 2011 through January 2012.
Patients included were females presenting for consultation
regarding facial and/or neck rejuvenation who were agree-
able to inclusion in the study. Patients excluded were
males and females who had undergone any previous
surgical intervention or chemical denervation. Informed
consent to participate in the study was obtained; all
patients expressed understanding of the purpose of
the study, the intended application of the photographs,
and willingness to participate. The patients for the study
were recruited from patients, familiars, and individuals in-
terested in seeing a 3-dimensional rendition of their face
and neck through their enrollment in the study. The
3-dimensional images were examined in detail to establish
a proposed classification system for platysmal banding.6
Next, the grading scale developed from the images as
well as a collection of the volunteer photographs were pre-
sented to a validation population, who scored the images
based on the scale. The validation process involved the ran-
domization of 49 photographs of the anterior neck with ten
different patients’ photographs per grade on the scale. Each
photograph was assigned a number in numerical order.
These representative numbers were then entered into
Microsoft Excel 2010 (Redmond, WA) and randomized
through the randomization function. The photographs in
their randomized order were printed in a pamphlet and pro-
vided as a survey to each rater, who scored the images at
their leisure. (A sample copy of the survey is available online
as Supplementary Material.) Surveys were distributed in
Aesthetic Surgery Journal 35(6)
person to all senior-level residents (Post-Graduate Year III
and above), clinical faculty, and academic faculty of the
Department of Plastic Surgery at the Loma Linda University
School of Medicine. Thus, the rater group was comprised of
academic and nonacademic attending plastic surgeons as
well as senior-level plastic surgery residents. Though no
objective assessment of the raters’ experience and skill
level was made prior to participation, raters were assumed
to be proficient in clinical assessment with adequate skills
to evaluate various aspects of neck. However, this assump-
tion does introduce a possible source of bias in the study.
Statistics
After collection, the ratings from the completed surveys
were entered into a Microsoft Excel spreadsheet and ana-
lyzed for mean, standard deviation, and 95% confidence
interval. Next, the data from the validation was analyzed
statistically using SPSS through a two-stage process to
ensure both interrater and intrarater validity. The first stage
was analysis of the Intraclass Correlation Coefficient, or
ICC. The ICC was done to determine interrater reliability.
ICC values from 0.4 to 0.7 are “fair” to “good” while values
from 0.7 to 0.9 are considered “excellent.”7,8 Next, intra-
rater reliability was evaluated utilizing Cronbach’s alpha
calculated from the data collected. Cronbach’s alpha values
are acceptable if greater than 0.5, but are preferred to be
over 0.7.9-11
RESULTS
A total of 119 female volunteer patients were recruited for
this study from both patient and nonpatient populations.
The patients ranged in age from 24 to 78 years old, with the
average age of 49. Largely due to the wide range of ages
captured in the study, the volunteers provided a spectrum
of cervicomental aesthetics, with a great variety of platsy-
mal banding severity, for analysis and creation of a grading
scale.
The survey results, presented in Table 1, demonstrate
the descriptive statistics for all the data collected. For all
grades, the 95% confidence interval demonstrates the con-
sistency of the data as there are no overlaps between the in-
tervals or over the various ratings. The tables also contain
Intraclass Correlation Coefficients (ICC) for the interrater
reliability, calculated for all results that varied from the
scale value. Validation of this platysmal banding scale gave
results ranging from good to excellent values. This assess-
ment denotes degree of agreement between the various
raters, ranging from 0.6 (good) to 0.82 (excellent). The
Cronbach’s alpha for each grade further demonstrates
validity of the scale, confirming intrarater reliability, or the
amount of agreement within each rater’s responses.
Gupta et al NP143

Figures 1-5 demonstrate both clinical examples and and encased between the layers of the platysmal fascia. Its
graphic illustrations of Grade 0 through Grade 4 platysmal insertion is more complex, with some fibers inserting into
banding in the proposed platsymal banding scale. These the mandible while others continue cephalad to insert into
figures are accompanied by a detailed description of each various muscles of facial expression, ultimately transitioning
platysmal banding grade. to the superficial muscular aponeurotic system (SMAS).12-14
Medially, the platysmal muscle anatomy varies in regards to
DISCUSSION where it decussates, ranging from the fibers completely
joining in the suprahyoid region to the fibers traveling
The anterior neck plays a crucial role in facial rejuvenation, straight to the mental protuberance without interlacing.13
with a major contribution derived from the status of the pla- When occurring near the hyoid, the decussating platysmal
tysma muscle. The platysma originates from the pectoral fibers support the submental region. Absence of the decus-
and deltoid fasciae inferiorly. It is superficial, rectangular, sation, on the other hand, can leave the medial edge free,
contributing a vertical banding anterior neck deformity.5
Table 1. Platysmal Banding Validation Data It is important to differentiate between a midline decussa-
tion and a muscle-based line of tension, known as a pla-
Mean ± SD 99% CI Range tysmal band. The midline decussating edge may be visible
Descriptive Statistics horizontally; however, it is not the same entity as a band,
and the differentiation is important for treatment purpos-
Grade 0 0.09 ± 0.29 0.02-0.15
es. Lower grade true platysmal bands can be addressed by
Grade 1 1.49 ± 0.62 1.46-1.72 external treatments, such as neurotoxin injection. A
visible medial decussation border, on the other hand, gen-
Grade 2 2.34 ± 0.75 2.21-2.52
erally requires treatment through surgical methods. In ad-
Grade 3 3.07 ± 0.57 2.91-3.17 dition, the decussation contributes to the width of the
platysmal banding. A lower decussation potentially results in
Grade 4 3.96 ± 0.21 3.90-4.00
narrower banding, necessitating midline plication as a compo-
ICC Cronbach’s alpha nent of a treatment strategy to avoid recurrence. A lack of
Inter- and Intra-Rater Reliability
decussation, on the other hand, can lead to wider banding for
which treatment does not always require midline plication as
Grade 0 0.73 0.71 a component.5
Grade 1 0.60 0.68 Aging of the anterior neck, including the severity of pla-
tysmal banding, varies greatly between individuals. It is
Grade 2 0.82 0.81
heavily dependent on neck structure, with factors such as
Grade 3 0.78 0.77 skeletal support and body habitus playing a large role in
the aesthetics of the aging process. In a patient with a sig-
Grade 4 0.70 0.72
nificant amount of neck adiposity, the appearance of

Figure 1. Grade 0 platysmal banding as seen in this 31-year-old female (A) and as an illustration (B). No platsymal bands visible at rest.
NP144 Aesthetic Surgery Journal 35(6)

Figure 2. Grade 1 platysmal banding as seen in this 56-year-old female (A) and as an illustration (B). Mild platysmal bands
evident at rest. Bands do not appear along the full length of the neck.

Figure 3. Grade 2 platysmal banding as seen in this 55-year-old female (A) and as an illustration (B). Mild platysmal bands
evident along the full length of the neck at rest, less than 5 mm of elevation from the surrounding tissue.

platysmal banding is softened by a thicker, more adipose
soft tissue envelope. This would then correspond to a less
severe grade of platysmal banding on our proposed scale.
This scale was developed in a cohort of patients with
varying body habitus; however, degree of neck adiposity
was not specifically accounted for in this study. While
post-platysmal fat will have a minor impact on banding,
pre-platysmal submental fat may play significant role in the
visibility and diagnosis of platysmal banding and whole neck
aesthetics. In patients with a full neck, additional assessment
of preplatysmal submental fat pad by pinch, while the
plstysma is actively being contracted by the patient, could
improve the thoroughness of the evaluation.14 Depending on
the amount of preplatysmal fat palpated, the assessment of
platysmal banding would have to be adjusted as preplatsymal
fat can disguise and dull the appearance of platysmal bands.
Similarly, an anteriorly placed hyoid bone may significantly
blunt the cervicomental angle and be associated with more
prominent submandibular glands, leading to a less defined,
more ptotic appearance of the neck and, thus, a more severe
grade of cervicomental aging.
However, our primary goal is to provide an objective
scale of platysmal banding, as this is the key decision point
for choosing the type of neck rejuvenation to be performed
and few surgical techniques exist to reposition the hyoid,
though its position does affect ultimate aesthetic outcome
of rejuvenation. Only female patients were studied as females
comprise the vast majority of patient who present for neck re-
juvenation in our practice. Given the anatomic differences
between males and females and the differences in progression
Gupta et al NP145

Figure 4. Grade 3 platysmal banding as seen in this 71-year-old female (A) and as an illustration (B). Moderate platsymal bands
visible at rest along the full length of the neck, elevation at least 5 mm from the surrounding tissue.

Figure 5. Grade 4 platysmal banding as seen in a 68-year-old female (A) and as an illustration (B). Severe platsymal bands along
the full length of the neck at rest, elevation at least 5 mm from the surrounding tissue, with additional soft tissue ptotic banding
present laterally.

of aging, a separate scale would likely need to be generated to
address cervicomental aesthetics in the male neck.
Multiple components of the anterior neck contribute
to the aesthetics, with platysmal banding a prominent un-
desirable change. The banding appears as vertical bands in
the anterior neck secondary to the platysmal muscle fibers
separating, atrophying in some areas, and hypertrophying
due to hyperactivity in others.15 These vertical lines con-
tribute to the layman’s description of “turkey neck” and
can be very distressing to the patients. Techniques done to
ameliorate platysmal banding range from injections of bot-
ulinum toxin and other closed procedures to surgical plica-
tion, interruption, and re-draping in attempts to achieve the
desired anterior neck contour.12,16,17 Until the development
of this grading scale, there was a deficit of objective tools
for measuring both the severity of the platysmal banding
and the efficacy of these treatments by outcome.
As new pharmacological and technological medical
advances reach the market, we face an increasing array of
treatment modalities to improve the aesthetics of the neck and
lower face. Reliable methods of evidence-based evaluation
of these interventions are crucial to providing us with the
ability to discern differences, advantages, and disadvantag-
es among various techniques. In 1996, platysmal band char-
acterization by McKinney defined four classes of bands,
with class one being the least prominent and four being
severe banding at rest.4 However, further delineation as
well as validation of grading scales is crucial to their utiliza-
tion in evidence-based analysis. Recently, multiple validat-
ed assessment scales have been developed for various
NP146
components of the lower third of the face and neck.18 A val-
idated assessment tool for platysmal banding, however, has
yet to be published in the plastic surgery literature.
We realize that platsymal banding is one of a number of
factors that influence the aesthetics of the entire neck. Being
a complex 3-dimensional composition of skin, fat, muscle,
and bone, the neck is best evaluated by considering the con-
tribution of all these components. We are currently develop-
ing a validated assessment tool that incorporates jaw
distinction and cervicomental angle into the evaluation of
the entire neck aesthetics.
Another potential limitation of this study was the low re-
sponse rate to the distributed survey and the potential for
nonresponse bias. A total of 22 surveys were distributed,
with 12 (54.5%) returned. However, the average response
rate of survey participants to a distributed survey, even
among physicians, is known to be in the range of 35% to
75%.19 Our response rate fell within this range. Furthermore,
of those who responded, an even distribution of resident, ac-
ademic plastic surgeon, and nonacademic plastic surgeon
responses was obtained.
Our study, with its validated grading scale, addressed the
need for a validated assessment tool for platysmal banding.
This scale could be applied to future clinical and research in-
terventions to provide objective grading materials.
CONCLUSION
In this study, a validated scale was established to assess
the degree of platysmal banding in the female neck. This
grading system has potential application in the preprocedure
planning for patients considering face and neck rejuvenation
and could give clinicians objective criteria by which to grade
preoperative appearance and postoperative results.
Supplementary Material
This article contains supplementary material located online at
www.aestheticsurgeryjournal.com.
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.
REFERENCES
1. Dedo DD. “How I do it”—plastic surgery. Practical sugges-
tions on facial plastic surgery. A preoperative classification
View publication stats
Aesthetic Surgery Journal 35(6)
of the neck for cervicofacial rhytidectomy. Laryngoscope.
1980;90(11):1894-1896.
2. Ellenbogen R, Karlin JV. Visual criteria for success in re-
storing the youthful neck. Plast Reconstr Surg. 1980;66
(6):826-837.
3. Knize DM. Limited incision submental lipectomy and
platysmaplasty. Plast Reconstr Surg. 1998;101(2):473-481.
4. McKinney P. The management of platysma bands. Plast
Reconstr Surg. 1996;98(6):999-1006.
5. Rohrich RJ, Rios JL, Smith PD, Gutowski KA. Neck reju-
venation revisited. Plast Reconstr Surg. 2006;118(5):
1251-1263.
6. Leis A, Mattison G, Gupta S. Classification of the Lower
Third of the Face for Use in Cervicomental Aesthetic
Surgery Planning. In: American Society of Aesthetic
Plastic Surgery: The Aesthetic Surgery Meeting 2013.
7. Shrout PE, Fleiss JL. Intraclass correlations: uses in
assessing rater reliability. Psychol Bull. 1979;86(2):
420-428.
8. Van Ness PH, Towle VR, Juthani-Mehta M. Testing mea-
surement reliability in older populations: methods for
informed discrimination in instrument selection and ap-
plication. J Aging Health. 2008;20(2):183-197.
9. Bowling A. Research methods in health : investigating
health and health services. 2nd ed. Philadelphia, PA:
Open University Press; 2002.
10. George D, Mallery P. SPSS for Windows step by step: a
simple guide and reference, 11.0 update. 4th ed. Boston,
MA: Allyn & Bacon; 2003.
11. Gliem JAG, Rosemary R. Calculating, Interpreting, and
Reporting Cronbach’s Alpha Reliability Coefficent for
Likert-Type Scales. In 2003 Midwest Research to Practice
Conference in Adult, Continuing, and Community
Education. Columbus, OH: The Ohio State University,
2003.
12. Caplin DA, Perlyn CA. Rejuvenation of the aging
neck: current principles, techniques, and newer modifi-
cations. Facial Plast Surg Clin North Am. 2009;17
(4):589-601.
13. De Castro CC. Anatomy of the neck and procedure selec-
tion. Clin Plast Surg. 2008;35(4):625-642.
14. Nahai F. The Art of Aesthetic Surgery: Principles and
Techniques. 2nd ed. Boca Raton, FL: CRC Press, 2010.
15. Ramirez OM. Advanced considerations determining pro-
cedure selection in cervicoplasty.: Part two: surgery. Clin
Plast Surg. 2008;35(4):691-709.
16. Daher JC. Closed platysmotomy: a new procedure for the
treatment of platysma bands without skin dissection.
Aesthetic Plast Surg. 2011;35(5):866-877.
17. Saylan Z. Serial notching of the platysma bands. Aesthet
Surg J. 2001;21(5):412-417.
18. Narins RS, Carruthers J, Flynn TC, Geister TL,
Görtelmeyer R, Hardas B, et al. Validated assessment
scales for the lower face. Dermatol Surg. 2012;38:333-342.
19. Kellerman SE, Herold J. Physician response to surveys.
A review of the literature. Am J Prev Med. 2001;20(1):61-67.