Anatomy of the Neck
and Procedure Selection
Claudio Cardoso De Castro, MD, FACS
KEYWORDS
 Neck lifting  Treatment of neck deformities
 Rhytidoplasty  Anatomy of the neck
 Facial rejuvenation  Face lift
Among the most common and chief complaints of
patients who seek facial rejuvenation are the
deformities of the neck caused by the ageing
process. Neck deformities greatly accentuate
and emphasize the appearance of aging, causing
distress to many people and leading them to
seek surgical correction. During the evolution of
the procedure, many techniques have been intro-
duced. In the authors’ opinion, the surgical proce-
dures presently used to ameliorate neck aging
began with the proper understanding of cervical
defattening,1 the introduction of surgery on the
platysma muscle in the mid-1970s,2,3 the elucida-
tion of the anatomy of the superficial muscular
aponeurotic system (SMAS) in 19764 and surgery
on the SMAS in1977.5 In the 1980s platysma and
SMAS surgeries were incorporated completely in
rhytidoplasties. At that time, discussions concern-
ing the SMAS centered on whether procedures
involving the SMAS should be performed. Today
the discussion involves which (not whether) proce-
dures involving the SMAS should be performed.
From the early days to the present, many impor-
tant papers on this topic have been published.6–32
Usually signs of aging are noticeable first around
the eyes and lower third of the face and neck. Sub-
mental fat accumulation, excess skin, and platys-
mal bands become evident, distortions of the
mandibular contour are conspicuous, and the
facial outline changes from triangular to square
(Fig. 1). These alterations may take place in
combination or be isolated. The irregularities are
caused by skin sagging, by excess, abnormal fat
accumulation, and by varying degrees of flaccidity
of the platysma muscle.
Plastic Surgery Division, University of the State of Rio de Janeiro, Rua Carlos Gois, 375/307, 22440.040 Rio de
Janeiro, Brazil
E-mail address: cdecastro@uol.com.br
Clin Plastic Surg 35 (2008) 625–642
doi:10.1016/j.cps.2008.05.007
0094-1298/08/$ – see front matter ª 2008 Published by Elsevier Inc.
When planning procedures to correct the neck
alterations, one must keep in mind the many
factors that interfere with the final result:
1. Age of the patient: the younger the patient, the
more likely is an optimal result.
2. Skin: an elastic and well-hydrated skin provides
a better result than dry and inelastic skin.
3. Mandibular bone: the anatomic shape of the
mandible plays an important role in the defini-
tion of the neck. Results vary, depending on
the contour of the angle and also on the projec-
tion of the chin.
4. The position of the hyoid bone also plays an
essential role. A high hyoid bone limits the
attainable result.
5. The degree of flaccidity and thickness of the
platysma muscles and their anatomic variations
affect outcome.
6. Current practice involves the digastrics
muscles, but the author does o not recommend
operating on these muscles.
7. At present, the submandibular gland is
resected fully. The author does not favor this
practice, because the complications, when
they occur, outweigh the benefits.
8. The magnitude of the alterations must be
considered.
Fig. 2 shows different patients demonstrating
different aspects of neck deformities. An individual
approach is required to address the alterations
needed in each patient.
plasticsurgery.theclinics.com
The surgical correction of deformities of the
neck and the lower third of the face is an important
part of the facial rejuvenation. Rarely, neck
626 De Castro

Fig. 1. (A) Alterations in facial contour caused by the aging process. Over time, the tissues sag, giving a square
appearance to the lower face. (B) Proper management of these deep tissues repositions the sagging structures,
restoring the triangular form of a younger face.

Fig. 2. Patients who underwent face lift to correct neck deformities. The photographs clearly demonstrate the
individual differences among these patients in bone structure, the position of the hyoid bone, mandibular
contour, and amount of fat.
 Anatomy of the Neck and Procedure Selection 627

Fig. 3. (A) Frontal and (C) profile views of a 25-year-old patient who experienced extreme discomfort because of
the fat accumulation in her neck. (B) Frontal and (D) profile views of the same patient 6 months after liposuction
and chin augmentation.

deformities can be treated in isolation. Young
patients sometimes present with excess fat in
the suprahyoid region that creates a defect
that can be addressed by liposuction, because
condition being addressed is only lipodystro-
phy, without excess skin (Fig. 3). When
liposuction alone is performed for neck treat-
ment, anotherdeformity may be revealed
(eg, evidence of platysmal bands) (Fig. 4). In
summary, neck rejuvenation requires an individ-
ualized surgical approach for each patient; this
approach mainly involves undermining the
skin, removing fat, and addressing the platysma
muscle.
SMAS/platysma procedures are mandatory for
a successful outcome of the treatment of the lower
third of the face. This article focuses only on surgi-
cal procedures in the suprahyoid region.
628 De Castro

Fig. 4. (A) Preoperative view of a patient complaining of neck deformity who requested liposuction. The limita-
tions of the results that could be obtained without opening the submental area were explained to her, and she
found them acceptable. (B) Results after liposuction alone. Notice that the excess platysma that could be seen
after fat removal. The patient was satisfied with that result; the author was not.

SOME REMARKS ABOUT NECK ANATOMY
RELATED TO RHYTIDOPLASTY
A thorough knowledge of anatomy is essential to
perform properly the procedures presently used
for neck rejuvenation.
The author’s interest in anatomy was aroused by
Guerrerosantos’2 article published in 1974. The
author tried to review platysma anatomy but found
little information in anatomy text books. The author
then started to dissect cadavers to learn more
about platysma anatomy. He first focused on

Fig. 5. (A, B) These dissections exemplify the different shapes and sizes of parotid gland. The mandibular branch
can be seen passing below the inferior border of mandible and in front of the angle.
 Anatomy of the Neck and Procedure Selection 629

Fig. 6. (A–D) These dissections clearly demonstrate the diverse sizes and shapes of the submandibular gland. The
vessels and nerves also are evident in these cadavers. Operations in this area may yield terrible complications.
A large incision may be necessary to deal with a hematoma in this region in the postoperative period, and the
consequences may be catastrophic.
630 De Castro
Fig. 7. Type I platysma medial fibers. (A) Type I fibers join about 2 to 3 cm from the chin. (B, C) Type I fibers in
cadavers. Fibers can be more separated or less separated and differ flaccidity and thickness.
analyzing the relationships between the platysma
muscle and the mandibular nerve. He observed
that the mandibular branch of the facial nerve
always is below and approximately 0.5 to 1 cm in
front of the mandibular angle (Fig. 5A, B). (Authors
who have written on this topic include Dingman
and Grabb33 on the mandibular branch, Correia
and Zani,34 and Baker and Conley.35)
The author also noted the different shapes and
sizes of the parotid gland. This understanding
proved useful when SMAS dissection became
popular. The author realized that, because of the
different sizes and shapes of the anterior border
of the parotid gland, the statement that one should
not pass that limit was not true. In many patients
the anterior projection is extremely short. The
limited dissection of the SMAS is insufficient in
most patients.
Another important factor that must be consid-
ered is the diversity in shape and size of the
submandibular gland (Fig. 6A–D). This gland is
becoming a topic of discussion among plastic sur-
geons who are concerned with neck rejuvenation.
When the gland is ptotic, improvement can be at-
tained by repositioning the gland via the platysma/
SMAS pull. When the gland is hypertrophic, how-
ever, some surgeons advocate gland removal.
The author does not recommend gland removal
because the access to the submandibular gland
is not easy, the surgical field is restricted, and sev-
eral vessels in the area can be injured easily. The
author agrees completely with Baker36 regarding
surgery on this gland.
Throughout his anatomic review, the author
noticed variations in the insertion of the platysma
medial fibers. Thus, the author classified these
 Anatomy of the Neck and Procedure Selection
Fig. 8. Type II platysma medial fibers. (A) Type II fibers behave as a single muscle in the submental area. (B, C) Type
II fibers in cadavers.
fibers into three main groups. In type I, the most
common, found in 75% of cases, the fibers are
separated on the median line intersecting 1 to
2 cm from the chin (Fig. 7A–C). In type II (seen in
15% of the cases), the fibers are joined completely
in the suprahyoid region, behaving like a single
muscle (Fig. 8A–C). In type III (seen in 10% of
the cases), the fibers are separated at the median
line, but they do not interlace. Instead, they go
straight to the chin (Fig. 9A–C). Thus, depending
on their insertion, the fibers can be addressed
more or less separately or as a single unit. Varia-
tions in muscle thickness and in the degree of flac-
cidity also must be taken into account when
correcting neck deformities.37
Another significant point that should be stressed
is that platysma muscle inserts into the cutan-
eous muscles around the mouth. A proper
631
SMAS/platysma dissection repositions the tissues
of the lower third of the face. As do many authors,
the author of this article considers the SMAS/
platysma as a unique anatomic structure, with
SMAS being a continuation of platysma muscle.
SURGICAL TECHNIQUE
To lessen or eliminate the irregularities caused by
the ageing process, skin undermining, fat removal,
and platysma treatment are necessary.
Skin Undermining
The extent of skin dissection varies according to
the needs of each patient. In most patients the
author unites the dissection in the suprahyoid
region. This ample cutaneous dissection helps in
distributing the skin. In a high percentage of cases
632 De Castro
Fig. 9. Type III platysma medial fibers. (A) Type III fibers go straight to the chin without interlacing. Like type I
fibers, type III the fibers can have greater or lesser degrees of separation, thickness, and flaccidity.
a submental incision is done also. This incision,
which is 4 cm long, is placed about 3 mm behind
the submental crease to avoid a retraction. Previ-
ously, the author used a 3-cm incision, but adding
0.5 cm at each extremity causes no harm and
facilitates the surgical maneuvers. The extent of
skin dissection in the lower limit varies according
to the needs of the individual patient. When
performing skin dissection, one must be aware of
the jugular vein and the great auricular branch.
One should leave a fat layer protecting the skin
to avoid skin slough (Fig. 10A–C).
Lipectomy
Whenever necessary, fat removal is performed.
Closed liposuction is performed when there is no
need to use the submental approach. The surgery
starts with the liposuction. A 3-mm, three-hole
cannula with a T-shaped tip is introduced in the
chin or close to the ear lobe (Fig. 11). When the
procedure is being performed in the anterior part
of the mandible, one must take care not to injure
the mandibular nerve. If the submental incision is
used, skin undermining is performed. The author
then prefers open liposuction. Suction above the
mandibular border should be avoided; usually
there is not excessive fat in that area. After the
liposuction a superior lateral pull is performed,
and non-fat tissue may be elevated. When the lipo-
suction is completed, a revision is done, and any
excess fat is trimmed with scissors.8,14 In subpla-
tysmal lipectomy, only the excess is trimmed.
There is an anatomic gap between the platysma
muscles and mylohyoid muscle. If too much fat
is removed, the platysma muscle may heal in the
mylohyoid muscle, and re-entrance may occur
(Fig. 12). In such cases, treatment is not simple.
Platysma Treatment
Proper platysma treatment is fundamental in
correcting neck deformities. As stated previously,
the median fibers are separated or joined in the
 Anatomy of the Neck and Procedure Selection 633

Fig.10. (A) Demarcation of the areas to be undermined. In most of the author’s cases the skin dissection is joined
at the suprahyoid region. (B) Submental incision. The author prefers to perform this incision behind the natural
crease. An incision at this location provides a better surgical field and prevents a retracted scar. (C) The skin
dissection is ample, allowing a perfect readaptation and providing a natural neck contour.

Fig. 12. A patient in whom subplatysmal fat was

Fig. 11. Perioperative view of the open liposuction in removed. When one removes too much subplatysmal
the submental area. This cannula is very useful for fat, reentrance may result from the healing of platys-
fat removal. mal bands in the mylohyoid muscle.
634 De Castro

Fig.13. (A) Schema showing the rationale for the procedures described. (Right) The formation of the bands. (Left
top) The platysma is sutured without attention being paid to the excess muscle. (Left middle) The excess muscle is
removed to produce an even contour. (Left bottom) A regular contour is achieved. (B) Visualization of platysma
medial fibers. In this patient, they are separated. (C) Visualization of platysma medial fibers that are joined in the
suprahyoid region, presenting flaccidity. (D) Medial fibers on the right side have been dissected so that the excess
can be assessed properly. (E) Right and left fibers are dissected. (F, G) Excess muscle is resected. (H) Fibers are
brought to the median line to be sutured with no tension. (I) Fibers have been sutured. The markings show where
the section will be performed. (J) Perioperative view of the medial section. (K) Final aspect. (Right) Perioperative
view. (Left) Schematic drawing.
 Anatomy of the Neck and Procedure Selection
Fig. 13. (continued)
suprahyoid region. The degree of muscle flaccidity
and the muscle thickness differ among patients.
The author opens most patients. When in doubt,
the author performs a submental incision. He
never has regretted opening the neck, and in
some cases he is sure he would have obtained
a better result if he had incised the area. The resul-
tant scar never has been a problem. After the sub-
mental area is dissected, the medial fibers are
visualized, and the anatomic distribution can be
assessed. Then lateral muscular undermining is
undertaken to evaluate the how much excess
muscle should be removed. When the amount of
excess has been determined, it is removed. The
635
remaining fibers are sutured to the median line
without extra tension, providing an even, natural
neck contour.15 The author tries to give a natural
tension to the platysma in the median line. To
achieve a proper readaptation of the medial fibers,
a medial section as described by Aston38 is per-
formed. The proper removal of excess fibers
avoids any remanent muscle (Fig. 13). When mus-
cle excess is not evaluated properly, remanent
bands may show in the postoperative view
(Fig. 14).
A submental approach can be performed before
or after the treatment of the lateral aspects of the
face. When the suprahyoid region is addressed
636 De Castro

Fig.14. (Left) Preoperative view of a patient presenting with alterations in her neck contour. (Right) Postoperative
view. The lateral neck aspect could be even better if the submental area had been operated on.

Fig.15. (A) The patient presented with fibrosis after rhytidectomy. She had no hematomas. She was treated with
corticoid infiltration. Three sessions at 21-day intervals resolved the problem. (B) Results after treatment.
 Anatomy of the Neck and Procedure Selection 637

Fig. 16. (A) Indurations after hematomas. (B) Result after corticoid injections.

Fig. 17. (A) Perioperative view of a 54-year-old patient who had had a rhytidectomy but was unhappy with the
results at the neck and jaw line (arrows). (B) Eight months after a short-scar secondary facelift using a submental
approach and SMAS/platysma flaps.

Fig.18. (A) A 68-year-old patient requested a facelift. The major complaint was lower face and neck deformities.
(B) Results 6 months after a short-scar primary face lift using a submental approach and SMAS/platysma
treatment.
638 De Castro

Fig.19. (A) Frontal and (C) profile views of a 58-year-old patient who complained about deformities on the lower
third of the face and neck. (B) Frontal and (D) profile views only 45 days after primary rhytidoplasty with medial
platysma treatment and ample SMAS/platysma lateral treatment.

first, exaggerated tension applied to medial fibers
may pull tissues that should remain above the
lower extremity of the mandible.
COMPLICATIONS
As in any surgical procedure, complications can
occur.39
The most common drawbacks are contour irreg-
ularities, skin necrosis, hematomas, seromas, and
nerve injuries.
Contour irregularities may occur when liposuc-
tion is not performed perfectly or because of fibro-
sis. These alterations can be difficult to treat.
Corticoid injections sometimes are useful
(Figs. 15 and 16).
Skin necrosis is the worst complication. It can
occur in heavy smokers and when a thin flap is
done.
Hematomas, when present, must be drained.
Irregularities may appear but will disappear with
time. Occasionally they last for a long time, caus-
ing distress to the patient.
Seromas, when they occur, must be aspirated.
Irregularities also may occur.
Injuries to the mandibular nerve must be
avoided, but when such injuries occur, they usually
recover within approximately 3 months. The cause
can be trauma during infiltration, during the lipo-
suction, during the process of coagulation, or dur-
ing the dissection.
SUMMARY
The surgical procedures to correct neck defor-
mities require anatomic knowledge of the
region40–43 and a thorough diagnosis of the defor-
mities so that the appropriate technique for each
patient can be chosen.
Good results can be obtained by following the
steps described in this article (Figs. 17–23).
 Anatomy of the Neck and Procedure Selection 639

Fig. 20. (A) Frontal and (C) profile views of a 46-year-old woman who has a squared lower face, no definition of
the inferior extremity of the mandible, and neck deformities. (B) Frontal and (D) profile views 6 months after
a primary short-scar face lift with ample lateral undermining of SMAS/platysma and a submental approach for
treatment of platysma medial fibers. Notice the triangular appearance of the lower third of the face and the
attractive jaw line and neck contour.
640 De Castro

Fig. 21. (A) A 47-year-old patient presented with neck deformities. She also complained about the drooping chin.
(B) One year after primary rhytidoplasty with submental treatment, extensive SMAS/platysma flaps that helped in
restoring the chin contour, and removal of excess bands.

Fig. 22. (A) A 68-year-old patient complained about neck alterations. (B) Nine months after secondary rhytidec-
tomy using a submental approach, lipectomy by suction, and a small chin implant.

Fig. 23. (A) A 65-year-old patient who had severe alterations in the neck and lower third of the face. (B) Postop-
erative view 11 months after a primary facelift using a submental approach with extensive SMAS/platysma flaps,
as described in the text.
 Anatomy of the Neck and Procedure Selection
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