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    Neck contour: Open vs closed technique

    Somebody with a sense of humor created the “#turkeygobbler” Twitter hashtag for a session about optimizing neck contouring at The Aesthetic Meeting this week in Las Vegas.

    Funny stuff. But ridding patients of their troublesome wattles is a serious, difficult and potentially dicey business for plastic surgeons. Many aren’t comfortable with “opening the neck,” often because of concerns about safety. On the other hand, some surgeons feel excessive caution can lead to suboptimal results.

    Plastic surgeons with varying perspectives tackled the issue of subplatysmal surgery and neck contouring in a panel yesterday moderated by Robert Singer, M.D.

    Foad Nahai, M.D., FACS, professor of surgery at Emory University School of Medicine, believes that subplatysmal surgery has helped him gain better results. It’s useful “to optimize the result in carefully selected patients,” he says, and research suggests there’s no increase of hematoma. Nor, he says, does dry mouth appear to be a major safety issue.

    However, Louis Bucky, M.D., a plastic surgeon in Philadelphia, says he rarely opens the neck. For him, safety isn’t the sticking point. Instead, it’s the fact that opening the neck doesn’t come “free.”

    There are risks of incision irregularities — “many of these incisional problems are not easy to take care of” — and both recurrent bands and new bands, he says. “You can create new bands when you take two bands and turn them into one,” he says.

    Common neck issues like excess skin or fat, platysma laxity and platysma bands can be treated effectively with a closed approach, he believes. However, Dr. Bucky says, treatment of subplatysmal fat, submandibular glands and digastric muscle require an open strategy.

    Bryan Mendelson, M.D., who practices in the Melbourne area in Australia and is past president of the International Society of Aesthetic Plastic Surgery, acknowledges that he doesn’t “really enjoy neck surgery.”

    After all, he says, “most facial surgery is superficial.” Opening up the neck “is foreign territory for us.”

    He has seen positive results, however, and is most likely to open the neck in second facelifts. “No patient has reported a dry mouth,” he says, and hematomas are rare.

    However, “that doesn’t tell the whole story. One patient nearly died. It’s a bit like flying airplanes: The incidents of crashes may not be high, but the consequences are profound.”

    In the big picture, he says, “I wouldn’t encourage people to do this operation unless they’re comfortable.”

    Timothy Marten, M.D., FACS, a plastic surgeon in San Francisco, is more comfortable with opening the neck, and he says it’s an important tool because other approaches often aren’t sufficient on their own.

    It’s important, he says, to understand the distribution of the layers of preplatysmal, subplatysmal and deep cervical fat. The latter fat “should not be removed. You don’t want to take that fat out because it creates overly hollow necks.”

    The other two types of fat — preplatysmal and subplatysmal — are “where your good results lie,” he says. 


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