IDEAS AND INNOVATIONS

Concurrent Platysmaplasty and Genioplasty

Using a Novel Intraoral Approach
Robin T. Wu, B.S.
Summary: Facial aging patients frequently seek improved neck and jawline
Andrew T. Timberlake,
definition. Microgenia, or lack of chin support, is often overlooked or under-
M.D., Ph.D.
diagnosed in these patients. The authors propose a simultaneous genioplasty,
Karl C. Bruckman, in addition to platysmaplasty and face/neck lift, to address both soft-tissue and
D.M.D., M.D. bony components, and enhance the cervicomental area. The platysmaplasty
Derek Steinbacher, is performed in a novel fashion using the intraoral genioplasty incision. The
D.M.D., M.D. operative sequence includes intraoral incision, platysmal exposure, fat excision,
New Haven, Conn.; and
platysmal tightening, genioplasty osteotomy/fixation, and external skin redrap-
New York, N.Y.
ing (face/neck lift). Case examples are shown to illustrate appropriate candi-
date selection and results. Parameters for success include increased chin-throat
distance and definition, improved cervicomental angle, and soft-tissue rejuvena-
tion. The novel approach the authors describe enables discrete access to the
platysmal and submental region and provides bony definition to help optimize
the soft-tissue drape and definition.  (Plast. Reconstr. Surg. 145: 80, 2020).
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

A
well-defined neck and jawline are important
to a youthful aesthetic appearance.1 Facial
aging results in soft-tissue skin laxity, jowls,
and platysmal banding, which may be addressed
using platysmaplasty and/or face lift.2–5 Fre-
quently, the central platysma is accessed through
an external submental incision at the time of the
face lift, allowing fat removal and dissection/pli-
cation of the platysma.6 Although this scar usually
heals and blends well, it may be noticeable and act
as a tell-tale sign of a neck lift.7
Poor cervicomental definition is not always a
soft-tissue problem alone.8 A degree of microgenia
can accentuate jowls and submental tissue redun-
dancy.9,10 Previous work advocated for simultane-
ous genioplasty and face lift for increased chin
projection and tightening.11,12 We believe osseous
or alloplastic genioplasty performed in concert
with face/neck lift and platysmaplasty provides
further definition, and fills the skin envelope.13
From the Department of Surgery, Section of Plastic Surgery,
Yale University School of Medicine; and the Hansjörg Wyss
Department of Plastic Surgery, New York University Lan-
gone Health.
Received for publication March 18, 2019; accepted June 20,
2019.
The first two authors contributed equally to this work.
Presented at the 2018 Annual Meeting of the Northeastern
Society of Plastic Surgeons, in Boston, Massachusetts, Octo-
ber 26 through 28, 2018.
Copyright © 2019 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000006392
The purpose of this report was to (1) advocate for
diagnosis and correction of microgenia in patients
seeking face/neck rejuvenation, and (2) describe a
novel intraoral approach to perform both the pla-
tysmal/submental manipulation and genioplasty.
OPERATIVE METHODS
The operative sequence includes the follow-
ing: (1) intraoral incision, (2) submental and
platysmal dissection and plication, (3) osseous
genioplasty, and (4) skin redraping with face/
neck lift. In preparation, perioperative antibi-
otics are given and the mouth is irrigated with
chlorhexidine gluconate oral rinse. Before inci-
sion, tumescent and local anesthetic is injected
into the subcutaneous plane along the facial and
submental/submandibular planes. Local anes-
thetic is injected in the mandibular labial vestibule
as well. A lower lip vestibular incision is opened,
preserving the cephalic cuff of mentalis muscle
and median raphe.14 Subperiosteal dissection
Disclosure: Dr. Steinbacher received Synthes
­research grant support. There are no financial dis-
closures, commercial associations, or conflicts of in-
terests for any of the other authors.
Related digital media are available in the full-text
version of the article on www.PRSJournal.com.

80 www.PRSJournal.com
Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 145, Number 1 • Simultaneous Platysmaplasty Genioplasty
ensues, exposing and preserving the mental
nerves and saving the mentalis muscle. [See Fig-
ure, Supplemental Digital Content 1, which dem-
onstrates the platysma, which is dissected in the
subcutaneous plane and freed subperiosteally
through the intraoral incision (above, left). Tack-
ing sutures are placed for platysma manipulation
during the platysmaplasty (above, right). Osseous
sliding genioplasty is performed and secured with
a titanium plate (below, left). The platysma is resus-
pended up and over the osteotomy (below, right),
http://links.lww.com/PRS/D841.] Plastic double
cheek retractors and toe-in/toe-out Obwegeser
retractors assist visualization.
The inferior periosteum is divided, a submen-
tal subcutaneous pocket is opened, and a skin flap
is raised over the platysma to the level of the thy-
roid cartilage, or further if needed, similar to the
transoral thyroidectomy approach.15,16 The anter-
osuperior platysma edges (at the inferior aspect of
menton) are grasped with two traction sutures for
mobilization and manipulation [see Figure, Sup-
plemental Digital Content 1, which demonstrates
tacking sutures placed for platysma manipulation
during the platysmaplasty (above, right), http://
links.lww.com/PRS/D841]. Retraction with a Rich-
ardson retractor and traction sutures then allows
for full platysmal (and subplatysmal) visualiza-
tion and manipulation, including defatting and
plication. If indicated, dissection of the anterior
digastric or submandibular gland can proceed
underneath the platysma. Permanent sutures are
then used to achieve the platysmaplasty.
Following defatting and platysma plica-
tion, the genioplasty bone segment is cut and
advanced/lengthened as planned, and secured
rigidly [see Figure, Supplemental Digital Con-
tent 1, which demonstrates (below, left) osseous
sliding genioplasty performed and secured with
a titanium plate, http://links.lww.com/PRS/D841].
The platysma tacking sutures are brought forward
and secured to the genioplasty segment and plate.
This further tightens the platysma muscle and
helps define the cervicomental region [see Fig-
ure, Supplemental Digital Content 1, which dem-
onstrates (below, right) the platysma resuspended
up and over the osteotomy, http://links.lww.com/
PRS/D841]. The pockets are all irrigated and the
mentalis muscle is redraped then secured. The
intraoral incision is then closed with chromic
sutures. To limit infection, gloves are changed at
this point in the operation.
The face/neck lift is performed through the
standard preauricular and retroauricular incisions.
The submandibular and neck cutaneous dissection
Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
extends and connects to the submental pocket
previously dissected and accessed intraorally. No
external submental incisions are created. The lat-
eral edge of the platysma and superficial musculo-
aponeurotic system can be lifted and then secured
in standard fashion. A single submandibular drain
may be placed (exiting behind the ear). Dressing
includes a head wrap and typical face lift and geni-
oplasty postoperative protocols.
CASE REPORTS
Case 1
A 58-year-old woman presented with complaints of facial
aging and a poorly defined neck (Fig. 1). She demonstrated jowls
and facial/neck skin laxity. Her lateral profile showed convex-
ity with lack of chin projection/definition. A short chin-throat
distance and obtuse cervicomental angle were present. Concur-
rent genioplasty, intraoral platysmaplasty, and face/neck lift was
planned for this patient.
Postoperative views show improved definition of the chin-
neck area (Fig. 1). The combination of bony support, platysmal
manipulation, and skin redraping provided aesthetic results.
This was marked by increased chin-throat distance, sharper cer-
vicomental angle, and elimination of jowls. No postoperative
complications were reported at 320 days’ follow-up.
Case 2
A 66-year-old woman with significant platysmal banding
and skin laxity was bothered by her neck (Fig. 2). The lack of
chin projection confounded/worsened the neck definition
and lower-third aesthetics. Concurrent genioplasty, platysmal
manipulation, and face/neck lift improved her facial balance
and lower-third aesthetics. No postoperative complications were
reported at 730 days’ follow-up.
DISCUSSION
Inadequate chin support superimposed on
facial aging can dramatically worsen lower-third
and cervicomental appearance. Microgenia, pres-
ent in at least 6.8 to 11 percent of the population, is
often missed or underemphasized, especially in the
facial aesthetic/face-lift patient.17 Concurrent geni-
oplasty, to set enhanced bony foundation, together
with face/neck lift and platysmaplasty is more pow-
erful than soft-tissue manipulation alone. Providing
chin support, concurrent with tightening and skin
redraping, creates a crisp and well-defined neck-
line with strong cervicomental angle. In addition to
recognizing the need for genioplasty in these face/
neck-lift patients, we describe a novel approach
whereby the platysmal and submental region are
accessed by means of the intraoral genioplasty expo-
sure, obviating an external submental skin scar. The
operative sequence involves intraoral incision/
exposure, platysmal and submental dissection, pla-
tysmal manipulation/defatting/tightening, osseous
81
 Plastic and Reconstructive Surgery • January 2020

Fig. 1. Preoperative (left) and postoperative (right) three-dimensional images of the

patient in case 1. Platysmaplasty, genioplasty, and face lift created increased chin-
throat distance, sharper cervicomental angle, and reduced jowling.

Fig. 2. Preoperative (left) and postoperative (right) three-dimensional images of the patient in
case 2. Platysmaplasty, genioplasty, and face lift dramatically improved chin-neck definition, with
elimination of platysmal banding.

genioplasty, and the external face/neck lift (with
lateral platysmal tightening and skin redraping).
Previously, genioplasties have been described to
accompany other procedures13 but, to our knowl-
edge, this is the first report to perform concurrent
genioplasty/platysma/face/neck-lift maneuvers, and
to complete the first two through the same intra-
oral exposure/incision. This approach benefits the
facial lower-third as a comprehensive unit, avoids a
scar beneath the chin, and offers improved visual-
ization and manipulation of the platysma/subpla-
tysmal/submental skin and osseous chin through
the single, hidden exposure. Although an external
excision directly overlies the platysma, the incision
is often limited to reduce scarring. The intraoral
approach allows for an extended incision window
and thus better exposure and visualization. The pla-
tysmaplasty is performed before the genioplasty, as

82
Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 145, Number 1 • Simultaneous Platysmaplasty Genioplasty
the visualization and access is better with the bony
chin recessed (rather than working behind and deep
to the newly augmented chin). Following genioplasty
fixation, the platysma is further tightened and resus-
pended anterior to the segment and hardware, creat-
ing improved definition. The face/neck lift creates
the finish, tailoring and redraping the overlying skin
to follow the new/improved submental and chin
contours.
Conceptually, connecting the exposure intra-
orally and externally/cutaneously could increase
infection from contamination with oral flora.18 How-
ever, we have experienced no infectious complica-
tions, and studies from trauma or reconstructive
series have shown no increased risk.19–22 It is prudent
to prepare with oral rinse and copiously irrigate the
intraoral exposure. We close this incision, irrigate
once more, and change gloves before turning to the
external face-lift incisions. Using perioperative anti-
biotics and repeated preparation of the face before
skin incisions may also help minimize infection.
SUMMARY
Patients with face/neck aging and lack of cer-
vicomental definition should be evaluated for pos-
sible concurrent genioplasty/chin augmentation.
The bony chin deficiency is frequently under-
emphasized, but platysmaplasty/face lift alone is
unable to create the well-defined, crisp neck lines
in these patients. Both the platysmal/submental
modification and genioplasty can be performed
through a single intraoral exposure.
Derek Steinbacher, D.M.D., M.D.
Department of Surgery
Section of Plastic Surgery
Yale University School of Medicine
330 Cedar Street
3rd Floor, Boardman Building
New Haven, Conn. 06520-8062
derek.steinbacher@yale.edu
Instagram: @dereksteinbacher
Twitter: @SteinbeastMD
PATIENT CONSENT
Patients provided written consent for the use of their
images.
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