‘Tuw LanyNooscore 90:1980 “HOw I DO IT” — PLASTIC SURGERY Practical Suggestions on Facial Plastic Surgery A PREOPERATIVE CLASSIFICATION OF THE NECK FOR CERVICOFACIAL RHYTIDECTOMY.* Dovua.as D. Depo, M.D., West Palm Beach, FL. INTRODUCTION. The myeloplasty or facelift operation has been the basis for rejuvenation of the lower one-third of the face and upper two-thirds of the neck for years. The ideal postoperative result is not only an acute cervicomental con- tour, but one that lasts for several years. Unfortunately, this is not always achieved when recurrent fullness from fat and muscle slowly becomes ap- parent in the submental area as the edema subsides 6 to 12 months after surgery. In an attempt to improve the cosmetic result and tailor the surgi- cal procedure for each patient, I use a preoperative classification of the neck that is based upon the abnormal anatomy causing the cosmetic de- formity.2 CLINICAL APPLICATION, Classification of the neck is not a new concept. Vinas in 1972? su; ed that the submental deformity be categorized according to retrognathia, ex- cess tissue, or a combination of both, Brennan and Brennan in 1976* pro- posed a classification of the cervical unit based upon the platysma muscle. It is apparent from cadaver dissections of the neck and lower face that a logical classification could be established based upon the anatomical layers of the neck. Figure 1 summarizes six classes of patients that may be identified when evaluating patients for the facelift operation. The first class of patient has a well defined cervicomental angle with good platsyma tone and absence of fat. In general, these are the younger patients, The second class begins to show sagging cervical skin without excess fat or platysma banding. The third class of patient has adipose tissue in the cervical area either of con- genital or acquired origin. The fourth class of patient is based upon the next layer in the neck — the platysma muscle. Brennan and Brennan* have shown that this muscle may be prominent in repose, or, accentuated by vol- untary contraction. The fifth class of patient has either congenital micro- genia (or) a relative retrognathia from atrophy of the soft tissues and bone absorption. The sixth class of cervical deformity is characterized by : low lying hyoid bone with or without any of the aforementioned abbera- ions. CLASSIFICATION: HOW IT WORKS. Performance of the same facelift operation on all patients is one of the most frequent causes of incomplete cervicomental contouring. This is simi- lar to doing the same rhinoplasty on all noses instead of tailoring the op- rom tho Department of Otolaryngology, University of Mlaml Medical School. gpg eprint Rewests to Douglas D. Dedo, MD., 1535 North Flagler Dr, West Palm Beach, 1894DEDO: RHYTIDECTOMY PRE-OP CLASSIFICATION. 1895 CLASSIFICATION OF CERVICAL ABNORMALITIES Class |: Minimal deformity-well defined cervical mental angle, good platysma tone, no accumulation of fat (younger patient). Class 1: Laxity of the cervical skin-begins to hang like a curtain. No fat accumulation, no platysma weakness. 4 < Class UII; Fat accumulation — \ lo ) Class 1V; Muscle accentuation ( banding present in repose or on contraction ) wz - \ 1G ke es Class V: Congenital or acquired retrognathia, Class VI: Low hyoid ( st fhe Fig. 1. eration to the anatomic deformity, This classification of the neck allows the surgeon to identify the anatomic deformity preoperatively. The surgical procedure is then carefully planned according to the class to which the pa- tient belongs. The Class I patient may be told to wait a few years if she (or he) wants to see a dramatic change following the pain and expense of sur- gery. On the other hand, if the patient understands that the operation will only help maintain the present visage for a few years, then doing a classic (and what I refer to as a “prophylactic”) myeloplasty with minimal under- mining would be indicated,1896 DEDO: RHYTIDECTOMY PRU-OP CLASSIFICATION, The Class II patient with laxity of the cervical skin will require wide un- dermining, plication of the SMAS and posterior borders of the platysma, As we progress to the next layer — fat — the Class III patient must be told about a submental incision. In addition to the usual rhytidectomy incisions, a second submental incision is made just posterior to the submental fold to facilitate not only undermining to the lateral flap areas, but also to allow removal of the submental and, if necessary, submandibular fat lying lateral to the platysma muscle, For these patients in their twenties and thirties with congenital fat accumulation, a simple submental lipectomy may be all that is required. ‘The Class IV patient with anterior platysma banding present in repose or contraction will also require a submental incision through which the an- terior borders of this muscle are resected, At approximately the level of the hyoid bone, a 2-8 cm. horizontal flap of the platysma muscle is created bi- laterally. These flaps then brought across the submental area and su- tured in the midline buried 4/0 clear nylon sutures, The posterior platysma borders are similarly identified, undermined, partially sectioned, pulled posteriorly and secured to the fascia of the sternocleidomastoid mus- cle with buried 4/0 clear nylon sutures, In effect, one has created a muscle sling for the neck to obliterate the anterior folds and accentuate the cervico- mental contour. I believe this muscle sling gives added support to the sub- mental area to reduce recurrent fullness, The next deeper layer — bone — is the key for the Class V and VI pa- tient. By identifying the Class V patient with microgenia, one may propose to the patient a chin implant which will augment the cervicomental angle by increasing chin projection and maintaining stretch of the soft tissues. he Class VI patient with a low lying hyoid bone must be identified pre- operatively to be able to discuss with the patient the limited success to be achieved from a cervicofacial rhytidectomy — regardless of the approach. In the preoperative evaluation of a patient for facelift, the cervical area is classified according to the deepest layer requiring manipulation. Notation of any other deformity requiring excision is also made, For example, Class TV means the patient has a prominent platysma and will require the pre- viously descrbed manipulation. Class IV with fat indicates the submental area will require sculpturing by fat excision prior to platysma excision and advancement, SUMMARY. An anatomic classification of the neck will not in itself guarantee a per- fect postoperative result. It will, however, make the surgeon more aware of the cervical unit and enable him to carefully plan the surgical procedure to obtain the optimum cosmetic result. This six part classification may be easily remembered by starting with the “normal” (Class I) and going pro- gressively deeped from skin (II), to fat (III), muscle (IV), and bone (V, BIBLIOGRAPHY, . 1, Depo, D, D.: Management of the Neck in Cervicofactel Rhytidectomy; Transactions of the ‘Third International Symposium of Facial Plastic and Reconstructive Surgery; In Press. 2, Vinas, J. C., er at.: Surgical Treatment of the Double Chin. Plast. Reconstr. Surg., 50: 119-192, 1972. 3, Brenwa, H.C, and Buswnan, L, G.: Correcting the Aging Platysma, Arch, Otolaryngol, eee ah: ar ‘orrecting the Aging Platysma. Arch. rung.