Hello, I'm Dr. Sarah Mess from Columbia, Maryland, member of ASPS, and I'm the Vice Chair of the Facial Aesthetics Program for PSTM 24, and I have an exciting panel for you, International Perspective on Facial Aesthetics. We have Leonard Minelli, MD, PhD, anatomy expert from Antwerp, Belgium, who trained with Dr. Brian Mendelsohn and is a Tagliacozee Research Fellow with Melbourne Advanced Facial Anatomy course. He is talking about the surgical anatomy of the platysma. Jair Maciel from Brazil specializes in the deep plane facelift and has a deep plane academy. He will give you the deep plane facelift, a step-by-step principle with excellent video on how-to technique. Andre Auswald is a plastic surgeon from Curitiba, Brunel, Brazil, who invented the hemostatic net and pioneered submandibular gland reduction. He's talking about isolated neck lift and hemostatic net. He will give us the principles of deep cervical neck contouring. Mike Nayak of St. Louis, Missouri is a facial plastic surgeon and a household name in the United States. He's a world-famous lecturer and a first-rate human being. He is talking about deep plane facelift fundamentals to finesse and giving us his update on his techniques. Ruth Graf is a plastic surgeon from Curitiba, Brunel, Brazil. She is a neighbor of Dr. Andre Auswald and she has over 70 publications. She's an excellent professor and inspires women plastic surgeons around the globe. And she also teaches the anatomy courses with Brian Mendelson in Melbourne and Mayo Clinic. She will talk about deep plane facelift, importance to know anatomy. So, you will definitely learn a lot and enjoy the panel, excellent presentations, and the question and answer. And I'm just really thrilled to have experienced this. Thank you. Neck improvement is of high priority to almost every patient seeking facial rejuvenation. And the results of facelift procedures are judged largely by the outcome obtained in the neck. A well-contoured neckline is essential to an attractive appearance. If the neck is not sufficiently improved, our patients will feel we have failed them. The most widely accepted approach to addressing the neck involves accessing the cervical region through a submental incision, platysma placature, associated or not to subcutaneous liposuction. Platysma placation is usually carried out with the patient in the Trendelenburg position. Much of the force exerted on the neck by the subplatysmal structures is alleviated in the Trendelenburg position, possibly leading to a false impression that the neck definition has been achieved while the neck is down. Similarly to what is seen in the content of this neck compared to the abdominal content. However, once the patient resumes standing up positions postoperatively, neck bulkiness caused by subplatysmal structures may reappear. Moreover, the platysma lacks bone insertions and is characteristically weak and fragile. Suture to tighten this muscle is unlikely to yield prolonged results because sutures and muscle become relaxed over time and the volume of deep set structures surpass the support that platysma muscle is capable of sustaining. The cervical regions behave similarly to rhinoplasty in the medium and long-term follow-up. The results obtained on the operating table does not often represent the final result. Re-interventions on secondary necks are not so infrequent in daily practice and requires a more comprehensive understanding of surgical planning. The excessive deep fat, large anterior digastric and myelohyoid muscles, protruding submandibular gland and or poorly positioned hyoid bone cannot be compressed against the uncompressible floor of the mouth and tongue within the fixed skeletal frame of the mandible. Necks can be categorized into two large groups, small cervical volume and large cervical volume. Cervicalplasty on thin necks tend to be more predictable, whereas in heavy necks tend to be less predictable, despite the medial and lateral tensioning of the platysma and removal of the subcutaneous fat. And that can be explained because other structures may contribute to neck's obliteration. Although lateral approach cervicalplasty is a commonly advocated practice, it is not enough to perform submental liposuction and tighten the skin in most patients, as such an approach ignores a number of anatomic problems present in many patients seeking neck improvement, including platysmal laxity, platysma bands, excess subplatysmal fat, large submandibular glands, digastric muscle hypertrophy, and developmental factors such as the size and shape of bony jaw, chin and tongue. Removing subcutaneous fat and tightening skin over these problems does not correct them, and the presence or absence of each must be looked for to create and apply a new We have added the upward view with the patient's neck flexed, which helps the surgeon to identify submental structures, define skin redundancy, and ascertain whether an open surgical procedure should be performed in the neck. This analysis can also be applied to the anatomy of the neck in motion, considering it is one of the most dynamic areas of the human body, and different anatomic configurations of the structures in the submandibular area may be observed when the neck is flexed. There are a few important surgical premises that are explained to the patients during consultation, and that surgeons who perform this procedure should also understand. This should minimize unrealistic expectations and establish the proper role for the procedure in neck rejuvenation. Isolated neck lifts, although durable for most patients, should be considered an operation to postpone a more traditional excisional cervical facial lift, as can be seen in this male, whose indication is at the merge of closed and open cervicalplasty. Non-excisional cervicalplasty was indicated despite the skin sagging was at the limit of an open surgery. Suplatismal structures were treated and skin accommodation was adequated, although not the ideal case for this type of surgery. The addition of structural support to the chin enhanced the final outcome for the neck. Our preferred method of chin augmentation is by placing a chin implant or fat grafting. This implant also helps in the treatment of submental crease. Deep cervicalplasty is the basis of closed cervical surgery. The deep cervicalplasty is a sculpting procedure that successfully accomplishes shaping of the cervical mental angle by both reductive and recontouring maneuvers that then allow the platysma to be redraped into the newly sculpted contour without counter forces that favors the strong muscles of the floor of the mouth. The goal of an appropriate deep cervicalplasty is not an extirpated procedure that removes as much suplatismal volume as possible. The results of a successful deep cervicalplasty sculpting procedure are measured by the remaining volume and shape of the contents achieved through the volume reduction and repositioning of the hyoid to meet the criteria of a beautiful neck. Every patient should undergo a unique procedure that manage each individual suplatismal structure based on preoperative indication and intraoperative findings and should be customized to patient specific findings therefore not every structure needs modification. Contour improvements of the anterior neck are achieved with two basic objective maneuvers volume reduction and repositioning of the hyoid bone. The large volume reduction of the suplatismal space is achieved through modification of the two largest masses the deep central fat with its medial extension and submandibular celebrary gland. Transitional volume reduction is achieved with modification of the anterior digastric muscles the perihyoid fascia and the mylohyoid muscle. This reduction is modest based on the relative volume of the total volume within the suplatismal space but very efficient in repositioning the structures at the floor of the mouth. Here we can see the digastric tendon being picked and sutured medially and the effect that this suture has on the position of the hyoid bone. This suture can be done in the digastric tendon when a more powerful elevation is desired or in the belly of the digastric when a lighter elevation is the surgical goal. It is important to highlight that this suture can cause discomfort in the first days after surgery. The reductive management of these structures is critical for creating an optimal cervical mental angle and a smooth transition from the submental to submandibular triangle. The quality of the skin changes over the years similar to the effects of a weakening of a rubber band. Skin is intended to be a covering layer and serves as a covering function. It was meant to stretch and give naturalness as we move and express ourselves. It was not intended to be a structural supporting layer or to hold up sagging muscle and fat or lift hypertrophy structures lying beneath it. Liposuction as a standalone treatment, it suffers the significant drawback that it falsely assumes poor neck contour to be solely the result of accumulation of subcutaneous fats and it is conceptually flawed in that it does not address platysmal laxity and other deep layer problems. The importance of maintaining ample supraplatysmal fat on the skin flap as a soft cushion has been previously emphasized. This preserved fat prevents skeletonization of the thyroid cartilage and decreases visibility of anterior neck irregularities. Good quality and tonnage of skin is fundamental for the success of an isolated neck lift. Look at this young male where only the anterior digastric bellies were causing cervical changes. Obtuse angles are better indication than sharp angles for isolated neck lifts. The straight red line comprises the shortest distance between the two points A and B and to the eyes excess skin appear to be present. In the B-line, the skin is not to be present. In the post-operative condition on the right, suplatysmal fullness has been eliminated and a deeper, more concave and geometrically larger and longer neck surface has been created. The skin is redistributed over a curved line that takes a longer path between the two points. Here we see the comparison of two young patients with similar cervical aesthetic needs but with different approaches. The top patient had neck liposuction with chin implant. The bottom one with the structured neck lift and chin implant. In the dynamic movement, the difference between the two treatments is more evident. The muscle of the neck, mainly anterior deltoid, is more The muscle of the neck, mainly anterior digastric belly and the position of the hyoid in the second patient are better defined. The hemostatic net greatly contributes to isolated cervical plasty as it facilitates the distribution of the skin after the treatment of deep set structures and platysmal plicature. The skin is stuck down to the platysma with a continuous running suture with a 5-0 nylon and a 25 to 30 millimeters long needle. With the use of the net, the skin is stabilized in the desired position for three days when it is removed. This makes the distribution of the skin much more suitable than garments, in addition to preventing hematomas. This is the ideal candidate for isolated cervical plasty due to the good quality of skin and the presence of hypertrophy of subplatysmal structures. Observe in this young patient that improving neck contour by excising redundant subplatysmal fat and performing other deep layer maneuver as indicated, followed by reducing horizontal platysmal laxity, will result in a deepened cervical mantle angle, a longer curvilinear distance from the mantle to the sternal notch, and a more concave and geometrically larger and longer neck surface. Hello, I'm Ruth Guerra from Brazil, and I wanted to share with you my experience in deep-plane facelifting. We talk about the importance to know anatomy, and I have no disclosure for this presentation. I just worked at the MFAC cadaver course with Brian Mendelsohn. The key takeaway for this presentation is how to do it safely, and the importance to learn facial anatomy to avoid nerve injury. In my evolution, I started with this mass flap for facelifting since my training, and then after Daniel Baker's presentation, I worked with smassexomy and fame, and after seeing the anatomy that Brian Mendelsohn teach us, I started to do the deep-plane facelifting. So nowadays, I do deep-plane facelifting. Let's talk a little bit about the layers of the face. We have here the superficial fascia, the frontalis muscle, the orbicularis, and the platysma. In between them, we have this mass, and deep to that structure, we have the deep temporal fascia, the periosteum, and the parotidemastatic fascia. In between them, we have the layer four that is the deep plane. We are going to work exactly at this layer four in order to release these ligaments and preserve the nerves. You can see here the composed flap that elevates the orbicularis oculi muscle, this mass, and the platysma at the same time. So where is the entry point for this flap? It is lateral to the orbicularis oculi muscle. We trace a line that goes until the mandibular angle and then go lower to in front of the sternocleidomastoid muscle in order to elevate the platysma together in this entry point. As you observe here in this defection that I perform, here we have the orbicularis oculi muscle, here is the mandibular angle. So we have this line going until here and go to the platysma, to the neck, and then I do this cut off here, cut back here, three to four centimeters below the mandibular angle in order to rotate this composed flap. So the subcutaneous flap is just one centimeter in front of this line. And we have to release these ligaments during the procedure. The orbicularis retain ligaments, zygomatic ligaments, and the masseteric ligaments to enter to the deep face. And just to show you here, how is the ligament? How are the ligaments? So the orbicularis retain ligaments, you can observe here between the pre-zygomatic and preceptor space. We have the zygomatic major muscle here and the superior zygomatic ligament and the inferior zygomatic ligament. And here the masseteric ligaments. Again, you can observe here the zygomatic major muscle and the superior inferior zygomatic ligaments. And here the orbicularis retain ligament between the pre-zygomatic and preceptor space. We have here the red carpet that we say that is the zygomatic major muscle. And here is the superior zygomatic ligament. And here is the inferior zygomatic ligament. As you can see here, the shape of the ligaments like that and the nerves run, travel exactly in this direction on the floor of the spaces. And when you release the ligaments, you observe that the compulsive flap is completely mobile. Then you can elevate the flap, all these deep flap together with the skin. And we have, of course, the nerves that is going to be on the floor of the spaces. As you see here in this Minelli description, the nerve is inside the deep fascia. So if it's inside the deep fascia, you have to go a little bit higher, close the platysma muscle in order to preserve the nerve that is inside the deep fascia. When you remove this deep fascia, you'll see the nerves as you can see here in this dissection that I performed. And you'll see here the superior buccal branch and the inferior buccal branch close the facial fat pad. And here you'll see the inferior buccal branch that stay just inside the deep fascia here, close the masseter muscle. And you'll see the difference. You see here a ligament. This ligament you release in order to maintain the nerve. You see there the nerve going to the mimetic muscle. And again, you'll see that the nerve is on the floor of this space. Then we can work in this compulsive flap stately. And here is the zygomatic major muscle. And sometimes you'll see a zygomatic branch here over the muscle, but the main trunk is run below the zygomatic major muscle. And you are going to see how I perform the procedure. This is the entry point at the masseteric ligament, the lower premasseter ligament space. And you'll see this areola tissue. So the nerve is there on the floor of this space. And then we can work above that, exactly create this space at the face, the lower premasseter space. And then we go with the trepsat until the jaw, as you observe here, releasing this space here. And for the prezygomatic space, I go under the orbicularis oculi muscle on the top of the zygoma bone. So you'll see that we have on the floor, the periosteum of the zygoma bone. And it's very safe because we have no nerve over the bone and then I can go until the nasolabial fold. And then between them, I look for the red carpet, the zygomatic major muscle, where we are going to release the zygomatic ligaments. You'll see here how strong is the ligament. This is the lower, the zygomatic ligament. And then I'm going, another ligament you have here, that we cut close the flap. And then I look for the superior zygomatic ligament over there. You'll see here the superior zygomatic ligament that I released in order to elevate the flap, the composed flap. And then we have here the buccal fat pad and superior to the buccal fat pad is the superior buccal branch and inferior, you have the inferior buccal branch. Exactly over the deep fascia of the masseter muscle. And again, just to show you the zygomatic ligaments inferior to the zygomatic major muscle. You'll see how strong is the ligament is the difference between the ligament and the nerves. You'll see that it's very strong that we have to release this ligament in order to elevate the flap. And between the pre-zygomatic space and preceptor space, we have the orbicular retained ligament that we release this ligament in order to treat the tear trough also. And to the neck, I go lower below to the platysmal muscle, open the platysmal muscle in front of the, the sternocleidomastoid muscle and go until the midline. So we can release inferiorly here, avoiding to go to the mandibular ligament. And then you have here the composed flap, we see under the platysma that we can mobilize totally the face and neck. And I cut the platysma just three to four centimeters below the mandibular angle in order to elevate the flap and suture the flap in a very vertical way, as you observe here, to the fascia, to the path, but it's the auricular fascia in front of the ear. As you observe here very strongly, I elevate the flap and suture. And suture superior. And then I elevate the orbicularis oculi muscle, as you observe here, suture to the deep temporal fascia, superficial temporal fascia. And the neck, I elevate and suture below the mandibular angle. And then here, I do the running suture in order to elevate the composed flap. As observe, again, I suture the lower part of the platysma to the mastoid fascia behind the ear. So we can elevate all the composed flap. And after that, I just remove the skin without tension. And you'll see how is the flap, that the subcutaneous flap is very short, because of this, we have almost generally no skin necrosis. I'm going to show some examples. This patient, I did the endobrow facelift and blepharoplasty. Here, she is one year post-op. You see how improved the mid-face, the jaw, all the mandibular line. You see the mandibular angle that we can project even more. And we treat the neck at the same time. You'll see how is the neck angle here. And when we cut the platysma very low, we can elevate even more the flap, as I do like very vertical way to suture behind the mandibular angle. So we are going to project more the mandibular angle. And the inferior part, I suture to the mastoid fascia. So you see how we elevate the platysma like around five centimeters superiorly in order to improve the neck contouring. And the mid-face, I go a little bit more obliquely in order to improve the nasal labial fold too. And another patient, one year post-op, you see how is the mandibular line, how we could improve the jaw, improve the mid-face for her and the neck at the same time. And I did liposuction because she had fat over the platysma. And you see how is the vectors for these two flaps here, the superior part of the platysma, inferior part of the platysma that I cut, doing these vectors for the treatment of the platysma. And another patient, more and more young patients come to me nowadays in order to improve their faces. And you'll see how we could improve this facial neck angle here with this technique. This case I brought for you, the long last result in three years post-op. You'll see again how is the mandibular line here, how we could improve the tear trough, the nasal labial fold, the mandibular line and the neck at the same time. How young is the patient with very natural result. Here she is three years post-op. In men, I do a similar procedure. You see this case that I treat exactly as I showed you, it looks like a sub-mandibular gland, but with this tension that I perform to the platysma superiorly, I could treat completely in this case. And I brought for you the last case that I had to treat the deep neck medially too in order to improve even more his result. It was very lax band medially and then I need to treat for him the neck medially too. Here he is one month, three months, and here one year post-op, very happy patient, patient 85 years old that was very happy with his result. Here he is three months and one year post-op doing this technique laterally in conjunction with the medial platysma application. So in conclusion, we have good acceptance by the patients. They look for deep plane facelift at the social media nowadays. We have less skin undermining with the composite flap, strong mid-face lift. We can improve the nasolabial fold at the same time. As you could observe, we have the redefinition of the neck without medial platysma application in some case, but using a very heavy neck, I use the medial platysma application to treat the neck deeply at the midline. We also avoid the skin necrosis and nerve injuries when we go no anatomy and when you go deep and undermine very shortly the skin flap. So thank you very much for your attention. Hello everyone. It's my pleasure to be here. Thanks, Dr. Sara Mez for inviting me. My name is Shair Maciel, I'm from Brazil. I'm gonna talk about deep plane facelift step-by-step. Deep plane academy is my conflict of interest, is a course in Brazil when I have two or three surgeons, two colleagues to observe and discuss my surgeries during a week. We are doing five or six facelifts in a week, they observe and we discussed everything. I'm very thankful to this guy, this giant, Andrew Giacono and Mike Nayak. They taught me everything about deep plane facelift. So I'm very thankful to them, Andrew Giacono and Mike Nayak. This technique was published by Giacono in 2018 and later in his book, everything is about this mass. This mass, you know, is divided in two parts, the lateral fixed mass and the mobile medial mass. And the patient comes to you and say, doctor, my face is falling down, jaws is bothering, and this part in my face is falling down. So you should lift this part, not the lateral part, but the medial mass part. A facelift is like an advancement flap surgery, you know, and one of the principles of this reconstructive surgery is you should release the flap to have movement, to have the advancement. So in facelift, you need to release the ligaments, the retainer ligaments. And these ligaments in your patient, on your table, these ligaments are vertical structures. Unlike the branches, the facial branches are horizontal. That's the difference. They are very close ligaments and facial branches, but ligaments are vertical and branches. Facial nerve is horizontal, is tangential. This picture, this picture is very important. This mass is continuous in the upper part, continues to the superficial temporal fascia. In the lower part, it continues to the platysma. And when you remove this mass, what do you see? You see a fascia. In the middle of the face, you see the parotid masseteric fascia. In the upper part, the deep temporal fascia. In the lower part, the deep cervical fascia. It's always the same fascia, only change the name. Giacono showed us that if you don't release the ligament, the zygomatic ligament, you can move, you can lift the myelofat path. What is the result? The result, the outcome is a pitotic midface, pitotic myelofat path, plus a fat graft. So it's not natural. The result is not natural. If you release the zygomatic ligament, you can move, you can lift the myelofat path with beautiful result, with beautiful and natural outcome. Our dissection is preorbicularis to avoid damage to zygomatic branch. Our dissection is on top of orbicularis, on top of zygomatic major. If you are on top of these muscles, nerves are deep. It's a transposition surgery. Mobile is mass to fixed mass. Some difference from high-mass technique, the opening, the high-mass technique is more lateral, more lateral. In the deep-plane technique is more medial, the medial than the opening. The flap undermining is more laterally in this high-mass technique versus the deep-plane. Deep-plane is more medial like the target. Your target is more medial. You need to release and lift the medial part of this mass of the face. Deep-plane entry point is medial, but the suspension is high and lateral, like high-mass. These are my marks, the entry point, from the angle of the jaw to the orbital ring. I mark the frontal branch and my incisions. This is my hair prepare. I usually do a temporal lift together. This is my hair prepare. My assistant is doing this, preparing with a stapler, from one side to another side. And after that, we prepare the tube, anesthesia tube, like this, and my assistant is doing the infiltration of the neck. First of all, I start with the neck. But in this lecture, I'm gonna talk about the facelift, not the neck lift. So my facelift is start here with the infiltration. Deep dissection means deep infiltration. Superficial dissection means superficial infiltration. So medially to the entry point, I'm deep. Laterally, I'm more superficial with my infiltration, okay? This is very, very important. It make your surgery easier. I start with my blade, my 15 blade. I like hetero-triangles incision in front of the hair. Behind the ear is in front of the head again. I start my dissection with this blade, and then I change to my scissor. And I stop at the entry point, okay? Then I go behind the ear, start the dissection, the dissection with my blade, 22 or 23 blade. Then I change to my scissor. And I connect the subcutaneous space from one side to another side. My undermining is large. Releasing the lateral mandibular ligament. Now releasing the ligament. Then I go to the entry point, opening the entry point, put tension in the left hand, and open with the blade, okay? And open with the blade, okay? Leaving this tissue under the retractor. This tissue is the cuff. You need one centimeter or one and a half centimeter. I can see the fascia. And I go on top of the fascia, on top of the parotid with blunt dissection with my scissors. Over the parotid, over the masseter. Now I'm suplatismal. I changed the tip of my scissor. Now I go dissecting the zygomatic space, the zygomatic space with the scissor, then with my finger, same maneuver. Now I'm releasing the zygomatic ligament. And what I find is my red carpet, the zygomatic major. Now I change to my scissor again with blunt dissection. That is the plane over the zygomatic major. That is my plane over the zygomatic major. It's it. My face is free, is released. All the ligaments are released. Now I'm doing again my marks, my entry point, my jawline, and my lateral platysmal flap, the opening of this flap. The vector is towards the mastoid in the neck, and the face is vertical vector. Now I'm marking inside the lateral platysmal flap over the SCM, the external cradle mastoid. Now I'm opening this flap with the cautery. I used to do this with the blade, but now I'm doing with the cautery because my assistant is always looking to the lower lip. If the lip is moving, he can tell me, then I know that I look so close to the cervical branch. So this dissection is over the fascia, the cervical fascia, under the platysma, this dissection. Five centimeters majorly and five centimeters down. It's a good flap. My flap, my platysma flap, it's here. Look at this, the jawline, the improvement of the jawline. Don't believe, don't trust in one suture. I always do two or more sutures in this area. Lifting the face. I start at the angle of the jaw towards the direction to the tragus, the sutures, the first sutures. I usually do five sutures, five or six sutures. I use PDS 3.0 with vertical. I start with vertical vector, and then going up, I go changing this vector more laterally than vertical. Most important is release the ligament to move this flap. Now it's okay. I'm tightening these sutures. It's not applicatory. You don't need tension in the sutures. Always check your skin, always. Don't tighten so much because tension in the sutures can cause deformities, irregularities on the skin. So check, don't put so much tension. You don't need tension in this area. Release, release the flap, the skin in order to avoid the depression. Okay, now doing my myotomy, lateral myotomy or horizontal myotomy of the platysma and lifting this flap towards the mastoid. I'm doing this suture with Vicryl 2.0. Not only one, but two, at least two sutures. Look at this, the improvement. Okay, the beautiful contour, the jawline. Okay, management of the skin, the adjustment of the skin, vertical vector in front of the ear and behind here, not like this, not like this. Horizontal vector, you need bigger incision. Vertical vector, we usually do vertical, always do vertical vector in front and behind the ear. Okay, now it's removing the extra, the extra skin. And I used to do this, a drain and four or five sutures in the skin and the deep tissues too, to avoid hematomas. Usually five sutures. I used to do this. I was with four or five months without hematomas and happy. But guess what? Hematomas came back. So I changed it. If you want to go home and relax and have a glass of wine after your surgery, you need to do a hemostatic inhale to prevent hematomas. Now I'm doing, for every single patient, this kind of hemostatic inhale with nylon 3O we do. These are my patients. Look at the jawline. Look at the scars. You can't see any scar. Looking down, 50 years old patient, female. Look at the jawline. Look at the neck. Look at the scar. Have a face patient, have a neck, two or three months in the post-op. 60-year-olds patients without incision in the submentum. Look at the jawline. Look at the myelofat pads. Look at the jawline, the improvement in the neck. Patients are very natural and very happy. I am very happy with the results. They are, too. So my friends, I have to thank everyone. Have a nice day. Hello, I'm Dr. Leonard Minnelli from Antwerp, Belgium. And I'm the fellow of Dr. Brian Mendelson in the Mendelson Advanced Facial Anatomy course. And my lecture today will be on the surgical anatomy of the platysma muscle and the surgical implications, of course. So I don't have any conflicts of interest to disclose. Starting off with the platysma anatomy, starting off with the platysma anatomy, we're going to talk about the segments. We're going to talk about the mandibular ligament, which is the attachment of the platysma to the mandible. Then we'll talk about the depressor labia inferioris as an extension of the platysma muscle. And finally, I'll talk about the innervation and then the surgical implications of that. So first, the decussation patterns. The first pattern of decussation is the most common pattern. And that's where the platysma decussates between the hyoid bone and the menton, in between them. And that's in 75% of people. Then you have a much broader decussation pattern that's even below the level of the hyoid bone. That's in 15% of people. And this decussation pattern is, of course, has an advantage because these people will not have the anterior platysmal bands, as we will come back to later. And then in 10% of patients, there is no decussation at all. And the two platysma bellies go to the menton without actually intermingling. But if you really want to segmentalize the platysma, what usually is done is talking about the facial, the submandibular, and the cervical parts of the platysma. And while this is a very common way of doing that, the more functional way is to divide in the way that the insert into the mouth or the mandible. And then you can divide them in a pars modularis, pars labialis, and a pars mandibularis. And you can see that the pars mandibularis is split because of this muscle DAO attaching to the mandible, causing the mandibular ligament. So the mandibular ligament is really a key feature in the anatomy of the platysmal muscle. So the mandibular ligament really wasn't present if you go back in evolution. And that is because in evolution, the platysma used to go over the mandible directly to the lower lip without inserting into the mandible. But in old world monkeys, this is the first time that the DAO really started developing and started inserting into the mandible there, dividing that platysma up. And this mandibular ligament, if we look at this anatomy a little bit broader or a little bit more detailed, we can see that there's actually three muscles inserting there. Because originally, it was only the DAO splitting the platysma. But therefore, also the platysma and the DLI have to attach to the mandible at this area. So there's these three muscles. And this insertion is a very broad insertion. It's around 6 and 1 1⁄2 centimeters for males and 5 and 1⁄2 centimeters for females. So approximately 6 centimeters mean distance from the menton. Now, looking at this from a fresh cadaver, we can see that the DAO is the first muscle always lying on the top of the platysma and DLI, which is the second layer of muscles. Platysma and DLI, as we will talk about later, are continuous. And you can see that these three muscles attaching to the mandible are really causing that mandibular ligament. And you can see that the platysma always attaches a little bit further than the DAO, always a little bit more lateral. Now, if we turn that muscle around, we can really appreciate the attachment to the mandible. But we can also see the marginal mandibular nerve there, as well as the facial artery. So that is very interesting to see. And you can see this is a strong muscular attachment. It's a real muscular attachment. Now, we're just not going into too much detail. But if you think about a jowl, the posterior extent of the mandibular ligament does not border the jowl anteriorly, but actually is approximately at the maximal jowl fullness. And this is a totally different lecture altogether to talk about the development of the jowl. But we have to remember that the real deep part of the mandibular ligament goes deep to the jowl. Now, I want to really show you here this attachment of the platysma, DAO, and DLI to the mandible, and then show you the closeness of the marginal mandibular nerve, because the marginal mandibular nerve always closes within two millimeters of this mandibular ligament of the attachment of the platysma to the mandible. This is a very important finding. So next thing I want to talk to you about is the DLI, because we have segmentalized the platysma in these ways. But if we take a closer look at the muscles right here, we can see that the platysma runs under the DAO and comes out on the other side of the DAO. And that's what Claude Le Luan has called the DLL. That is the depressor labial lateralis. It's just a different name just to think about. It's still the platysma, but we think about it a little bit different because it has such an effect on the lateral lip, therefore the depressor labial lateralis. And then the real lower lip here is, of course, depressed by the depressor labial inferioris. And this DLI is actually an extension of the platysma, because as we know, the DAO splits this platysma. And if we were to look at this under the microscope, we can actually still see that. If we take a section like that, what do we see here? This is the plastination. You can actually see that the DAO goes actually, and let's zoom in here. The DAO goes through the platysma and DLI to insert into the bone. You can see those fibers right here. Whereas the DLI and the platysma, they kind of continue, and it's a crisscross of those fibers. You can really follow them under the microscope. This is a sheet plastination done by Gunther von Huygens from Germany. And if you take a section like that, a horizontal section, there you can really appreciate how the platysma and DLI are the same muscle and the DAO is simply lying on the top. And then the final part is the innervation. So innervation to the platysma is, of course, by cervical branches. But remembering that the DLI is part of the platysma, that explains that the DLI gets innervation also by cervical branches. And this is something that is fairly new. This is a fairly new way of thinking. And we can see here the cervical branch of the facial nerve. We can see the trunk of that. And then we can see one of the first branches that takes off from that trunk, goes straight to the menton. And you can see it always crosses over the submandibular glands very superficially. So it leaves the parotid gland very deep there. There was a lot of deep fascia had to be removed to actually visualize this because it's very deep within the deep fascia, that nerve. But then you can see multiple branches. You can see those, you know, this is multiple branches that you can see there going to the lower lip. Now, thinking of how deep they are, this is a very important question. So as I said before, they leave the parotid gland very deep. So if we look at these cervical branches and we take a section right there, we can see that the cervical branch leaves the parotid gland very, very deep, approximately half a centimeter deep. It's a lot, it's very deep. So if you're on the undersurface of the platysma, this is gonna be fine. But if we take a section more forward over the submandibular glands, or anterior portion of the submandibular gland rather, there we can see that those branches, and they are in yellow there, okay, let's zoom that in. They are now extremely superficial. They're almost against the platysma there, depending on, you know, we can, because they're going up now. So the lower we are, the more proximal we are. But then if we move up, the more distal we are. And you can see those nerves, they progressively go closer to the platysma. And we can also see that they're both close to the platysma as well as close to the submandibular gland capsule. And that's an important thing to remember when you're doing submandibular gland removal, as we will come back later. So to save, to make sure that these branches are safe in surgery, it's very important to respect those depths of those nerve branches and to be in the different plane, of course. So if we put the deep fascia, deep cervical fascia, on top of these deeper structures, now we can see that we have this deep fascia as a three-dimensional structure. The facial nerve branches are within that deep fascia, running from very deep in the deep fascia to if you follow them, they become more superficial and they become too live, very close to the platysma. And that's what we're seeing here. So if you're coming from laterally, you're doing a deep plane face and neck lift from posterior approach, preauricular approach and retroauricular approach, now you have to make sure you're very close to the platysma because you're gonna leave the nerve very deep. Okay, and you can do that all the way up to the submandibular gland and the nerve will stay deep as long as you are on the undersurface of the platysma. But if you come from the submental approach, now you have to have a different approach. Now you wanna, if you go lateral from the digastrics, if you go lateral, you're gonna be in the territory of the cervical branches and there you wanna stay deep. Why? Because the cervical branches are very superficial there. If you stay deep and you leave a layer of fat on the undersurface of the platysma, you're gonna make sure that their cervical branches are kept safe. So what are the clinical implications of this? If you were to harm the innervation to the platysma DLI, DAO, and of course we're gonna have lower lip dysfunction. Okay, another important issue with the platysma are of course platysmal bands. And that's what we're gonna talk about at the last part of the talk. So lower lip dysfunction is a very feared complication out of face-shift surgery because it's such a stigmata. Okay, this is a video that I could use from Jerry O'Daniel. Thank you very much for that usage. And you can see it's a stigmata. So it looks like this is the one, the lip that is affected, but of course the lip that's affected is the right side. And because it doesn't depress, and this is a DLI activity. Now, if you wanna, what are you gonna do with this patient? You're gonna have them evert the lower lip. And that's what you can see here, Donald Trump is doing that, is everting the lower lip. What do you see? You see dimples of the chin, you see the DAO activity from the sides. Okay, they work together to actually curl the lip around. Okay, and we see that the lower lip is actually curved around, okay. And we think that the DAO, at least the mentalis muscle is innervated just by marginal mandibular nerve. So if you're able to evert the lower lip, it means the mentalis muscle is intact, and that means that the marginal mandibular nerve is intact. Now, if you cannot do this test anymore, you know that the marginal mandibular nerve is harmed. But if you can still do this test, and you can still evert the lower lip, then we think that it's the cervical branch that have been harmed. And the good thing about that is that you have a lot of cross innervation, these are small terminal branches, and therefore we have yet to see a permanent case of isolated DLI weakness. This always comes back, at least that's with the most current knowledge. So this is a very important test for prognostic reasons. If you have a lower lip weakness, let the patient evert the lower lip. If you can still do it, you can confidently let the patient know that this is gonna be temporary. If he cannot do this anymore, this is a problem, and you may want to consider going back to look at the marginal and maybe make a repair. But this is completely a different lecture altogether. So finally, I wanna talk about the platysmal band. Platysmal bands are a pretty difficult clinical feature, it's an aging stigmata. And they're difficult to treat because there's a lot of recurrence. Now what is the etiology of platysmal bands? Why do platysmal bands form? Now we worked together with a biomechanical engineer from Oxford to actually tackle this issue, and we think it has to do with high mode buckling. Now high mode buckling is the feature that elastic or contractile sheets start forming wavy patterns in a viscous medium. And this is what happens with the platysma contraction. Now if you look at the platysma, the way it functions is that in the lower lip, it brings the lower lip down, and especially the lateral parts. That's why the one called that the depressor labia lateralis. The corner of the mouth and the very lateral part of the lower lip are getting pulled laterally and inferiorly. But the lower part of the platysma muscle is actually pulling upward, okay? And also it broadens the neck. And I'm gonna show this video. This is from Dr. Leo Valle in Belgium. And you can see here how if you're contracting the platysma, you can see that the skin is getting pulled upwards, but also the neck distends. The neck becomes broader. And you can see the platysmal bands get pulled forward. But this is a young person. As you can see, he has to put a lot of effort into creating those bands. So in a young person, you don't generally have static platysmal bands, which are the problematic bands to treat, really. And so platysmal bands are usually at three main areas. And they are mostly at the anterior border, at the posterior border, and then often there is a big platysmal band and also just lateral from the mandibular ligament. Why here? Because this is the area of most mobility. In the way that these parts of the platysma can recruit the most fascia. And why is recruitment of fascia so important? Because the platysma is fixed in this medium of fascia. And if the fascia is tensed and is young and elastic, you can't really pull these bands in a relaxed position. You have to really forcefully create those bands because the fascia will provide counter traction. And so that's what I wanna talk to you about now. So aging involves laxity of fascial layers. All of the fascia layers, the superficial fascia and the deep fascia become very lax with aging. There becomes almost a redundancy of mobility. And so in youth, these fascias, and they are illustrated by the blue lines, they are gonna be more elastic and so they're gonna provide more counter traction than the resting tone of the mimetic muscles. So the resting tone of the platysma muscle. And so you have to really pull very hard and you create that really active tone which you can see here by the red line that goes higher than the fascia tone. And that takes a lot of effort. But in aging, now the fascia has become so lax that the resting tone of the fascia is so lax and there is almost no tone anymore. There is so much laxity that the small, small, small resting tone of the platysma muscle is enough to create a band. And we know that with the facial nerve palsy patients that don't have platysma activity and those bands disappear. So we know that the resting tone of the platysma is an important factor in this formation of platysmal bands. So people say sometimes that these bands are there passively and therefore there is nothing to do with resting tone, but this is not the case because patients that have facial palsy, they can have on one side platysmal bands while resting and the other side they have no bands because the resting tone of the muscle has disappeared. Now, of course, if an aged person contracts platysma, these bands become even bigger, but this is a dynamic band and this is less of a problem often. And so I wanted to show you this fascia redundancy or at least the fascia mobility. So I'm gonna lift up the platysma in this case and I'm gonna just show you the fascia mobility that you can see what is going on. So if you look at this fascia, you can see how much movement that this fascia allows. This is around one and a half centimeters of movement. So one of the treatment options to do would be to release the platysma from this fascia and to tension it higher on this fascia so that a new balance is created between the fascia and the platysma. So that there is, again, this more of a tension state like we had in youth. And you could say, okay, the platysma is already released, but you don't have to release the platysma. You can see here this video from Daniela Beer who shows how much recruitment you can have on the platysma just by pulling on it without doing the release. But we have shown in our studies that doing that, you change the connective tissue underneath from a hanging down pattern, you can see it on the right now, to a lifted pattern like you see now. And that change from hanging to a lifting, we hypothesize that this is not good for longevity. And so doing a full platysmal release and then redraping it would hypothetically have a longer lasting effect and a better effect for platysmal bands than if you were to leave the fascia and platysma attached. And that's what we're showing here in this little video on the right. We show that if you move the platysma just upward, you're gonna have a better state of the platysma afterwards while leaving that deep fascia intact underneath and not changing that architecture from a hanging down pattern in which it can support gravitational sagging to an upward lifted pattern where it cannot support sagging any longer, okay? Now, you know, one of the options has been to transect the platysma, but showing by this nice illustration by our illustrator, Dr. Levent Efi, showing that the platysma is immersed within fascia. So superficial fascia and deep fascia are restraining the platysma. And therefore the platysma is not like any skeletal muscle that you can just cut and make it useless. If you cut the platysma muscle, it may go apart one centimeter, two centimeters, but the rest of the platysma will still function perfectly because it will still be able to contract and pull the skin and superficial fascia along. So you can see those bands don't go apart that much. So then some surgeon have described a deep fasciotomy, and this really helps to create a bigger gap between the platysma and render the platysma more useless. And if you combine that with even skin release, then of course the platysma can go apart even further. And doing that, all those procedures consecutively, you will render the platysma less and less able to create bands. But the question is if this really is physiological. Now, one of the last resorts that people have used in the past and still do is the platysma strip resection. And if you resect the pediplatysma, of course that part will not reform and will have a long-lasting effect. But again, what is the physiological effect of this? And this is really natural. Now, one of the other options that we're looking at is to do selective denervation, because now we know that there is cervical branches going up and going down into the platysma. And if we were to selectively do the cervical branches that go down to the platysma, we can selectively denervate the cervical portion of the platysma without really affecting the facial part of the platysma. And this is an option that we're looking at. And by this, I wanna end my presentation thanking you for your attention. Really thank Dr. Metz for the invitation to speak to you today. And if you're very interested in the anatomy, we have an anatomy course just after this weekend in Amsterdam. So everybody is welcome to fly to Amsterdam and attend the course. Thank you so much for your attention. I'm Dr. Mike Nyack from St. Louis, Missouri. And today I'm gonna talk to you about my deep plane facelift approach. I'm gonna start with the fundamentals of deep plane facelift, what's traditionally thought of as a deep plane facelift. And then I'm going to show you how I've evolved over the last few years, what I would consider the finesse approach to what I call the preservation deep plane facelift. I have no financial disclosures beyond the QMP videos that I put out. I do get a small royalty from the QMP videos. It's not significant. I put these out as a public service more than anything else. Other than that, no financial disclosures. I do have a Telegram facelift group I welcome you to if you're a facelift surgeon, either just starting out or super accomplished. Either way, you'll find the group very rewarding. It's very active, a bunch of great surgeons on there, lots of great mentoring, and I welcome you to join it. I want to say thank you to my mentors. So Mark Glassgold in 2003 was the first person to introduce me to deep plane facelifting. It's evolved a long way in the last 20 years, obviously, but he's the first person to introduce me to the deep plane facelift. He was my fellowship director. And then Tim Martin, really in around 2008, opened my eyes to how to truly sculpt the deep neck in the Canals fashion. And so these two really set the foundation for my facelifting career. The people towards the bottom of the screen, they're Andrew Benn, Mario Pelli, Giovanni, Jerry O'Daniel, Andre Arsvald. These are people that in the last 10 years or so have had impacts on me, and everything you're going to see today really stems from one of the people on the screen. So overview, we're going to go over a little bit of the anatomy of aging, the fundamentals of deep plane facelift, my recent changes in technique, and then just a few examples. Facelifting is like rhinoplasty. The surface contours are determined by deeper anatomy. So just like with the rhinoplasty, we want to unwrap the face, reshape the deeper anatomy, and then rewrap the face. That's what's creating the shape. So we want to balance volumes, not just lift. So initially, if you look at the two top pictures here, in the green is where most of the volume addition is required, and then in the warmer tones, the orange, the purple, the red, the yellow, that's where most of the volume reduction is required. Once we do those things, then we refit this mass snugly onto the new framework, and that's how we get a pretty restructured lower face and neck. This is one of my patients from many years ago. She's a great example of this. And what I've done here in these slides is I'm color-coding what was done to her volume-wise before this mass was refit. So she had a little bit of jowl liposuction, the tiniest little bit, that's the light pink right here. She had deep to this mass fat reduction, so central neck fat, orbital fat reduction. She had buccal fat reduction and submandibular gland volume reduction. At the very end of the surgery, tiny bit of subcutaneous fat sculpture, but she also had fat addition, the infrabrow, the tear trough, miller cheek, zygomatic cheek, pogonion, pre-jowl sulcus, gonial angle, little bit into the folds. And all together, that creates a beautiful shape upon which we can re-drape this mass. So neck rejuvenation is largely deep subtraction. What I mean by that is if you look at these diagrams, you can see the platysma in this MR, you can see the platysma, and most of the volume change accessible, available here, is deep to the platysma. So if you only did subcutaneous fat sculpting and tightened the platysma as much as possible, you're going to be limited by this diagonal line. On the other hand, if we sculpt the fullness deep to the platysma, the digastric muscle bowing, the subplatysmal fat, we can create a completely different neck shape. So in order to create the optimum neck shape, depending on where the anatomy starts, we're going to need a whole toolbox, and we're not going to go into that entire neck lift toolbox. In this presentation, I have a different one entirely that I give on that, but it's not a one-size-fits-all segmented plasty. I think it's probably the most important thing to remember. In this presentation, we're going to focus on the lateral face. This is a deep plane facelift talk. So these are all the things that I have done over the years. I've done literally every one of these in the last 20 plus years that I've been in practice, but this is the only one I really still do anymore, and it's the deep plane facelift. I've made some modifications I'll show you, but when you're first starting out in practice, a SMAS plication lift or a purse-string style max lift, that's a nice thing to do. You can raise a big skin flap, make a really nice change, probably get 80% of the result of a deep plane with minimal anatomical challenges and sleep really well at night. As you get further and you want to see really elegant shapes, tension-free shapes, really great changes in the anterior segment of the face, I really don't think there's anything aside from a deep plane or deep plane extended facelift that really gets that to happen. So let's talk about the differences between a SMAS flap and a deep plane facelift. The traditional deep plane entry point is at the red diagonal line from the lateral orbital rim to the angle of the mandible. That's the traditional deep plane entry point. SMAS flap facelifts, we usually enter more posteriorly. So this is kind of a high SMAS design, meaning the superior incision is not at the inferior edge of the zygoma, it's up over it. The yellow is Pythagoras line. You can absolutely enter at or over that as long as you're lifting the superficial temporal parietal fascia strongly off the zygoma. It is safe to do that. The depth of either dissection, whether it's a SMAS flap or a deep plane facelift flap, either way, we're traveling through layer four. So layer two being the subcutaneous layer, layer three being the SMAS platysma temporal parietal fascia. Layer four is the potential space deep to the SMAS platysma temporal parietal fascia. The SMAS flap and deep plane facelift both undermine, elevate the face in layer four. So they're, in a lot of ways, very, very, very similar. It's just, do we delaminate the face in layer two broadly before we enter the deep plane and raise an independent skin flap? Or are we keeping layer three pretty much together with layer two and moving those in a composite fascia? That's the main difference between a SMAS and deep plane facelift, SMAS flap and deep plane facelift. The main difference between a deep plane facelift and a composite facelift is traditionally the deep plane facelift incorporates the platysma, the malar fat, but leaves orbicularis down. Technically, if you take orbicularis up as part of your composite flap, that's considered a composite ritidectomy. And when you see my surgical videos later, you will see that I actually do incorporate at least the inferior centimeter or so of orbicularis with my flap. So what I'm technically doing is a composite ritidectomy. So it's a deep plane lift. We call it colloquially, but technically it is a composite lift. Deep plane release traditionally has been focused on releasing the zygomatic ligament, the mandibular ligament, the platysma auricular ligament, and the masseteric ligaments. And that has been traditionally what we focus on with deep plane release. The masseteric ligament, the zygomatic ligament, the platysma auricular ligaments, these are all released in the subsMAS plane. The mandibular ligament is released in the subcutaneous plane. So traditionally the deep plane dissection, the landmark is the lateral orbital rim and the bony angle of the mandible. We raise a skin flap to that point and then enter the subsMAS plane at that point. Why is that the case? Well, we know we're going to be well ahead of the temporal branch of the facial nerve. All the other branches of the facial nerve are deep to the parotid masseteric fascia and well-preserved or deep to zygomaticus major. This one's a little more superficial. It's right under the temporoparietal fascia. And by designing this in the traditional deep plane entry anterior here, we know that we're incising this mass well anterior to the temporal branch. The temporal branch will be found at least 19 millimeters posterior to the lateral orbital rim. So by making this incision at the lateral orbital rim, you know for sure you're not going to injure the temporal branch. The deep plane dissection then is carried through in layer four. And again, we're looking for release of the zygomatic ligaments, the masseteric ligaments in the subcutaneous plane, the mandibular ligament. This is a traditional approach. That incision that originates at the lateral orbital rim and terminates at the angle of the mandible before coming down into the neck, that's very safe again from the temporal branch because this is anterior to the temporal branch. It's also very safe here at this section where it's over the angle of the mandible because that incision over the angle of the mandible is crossing the parotid. And so the facial nerve branches have not yet left the parotid. You can see in the red is where the incision in the SMAS is. You can see in the blue is the anterior edge of parotid. So that incision is, the nerves are protected from this incision by the parotid itself. And then the green is the nerves leaving. So that's why this incision design is so safe. It's anterior to the temporal branch. It's over the parotid. The nerve branches are super well protected here. This is what that surgery looks like. I have the skin flap undermined to that level, the line that's determined by the lateral oval rim and then the angle of the mandible. And now I'm using my electrocautery to open the SMAS, to enter the SMAS. I have my electrocautery on a setting of 18 to 20 coag depending on the machine, 18 to 20. And I'm incising the SMAS and then lifting up with my forceps. My assistant is lifting up on the composite flap and the potential space, especially here over the parotid and masseter shows really, really well. Up here, I'm feeling the zygoma. I'm making sure that I am truly over the zygoma because I wanted to find this flap in the pre-zygomatic space. And so again, my assistant is putting tension on the composite flap. I'm pulling posteriorly with my forceps and then we're incising. You can just see orbicular osoculi there. We're incising and I'm feeling to make sure that I'm well up over the zygoma. That pre-zygomatic space is perfectly safe. So we wanna make sure we're up there and that we're not inferior to the inferior edge of the zygoma digging into the midface. So these are where we establish the deep plane dissection, the safe, easy spot in the pre-zygomatic region and then the safe, easy spot over the masseter or the parotid masseteric fascia. And then we connect between these two layers and what we're looking for is this release of tension. So you can see the tension is not released here. We haven't truly entered the deep plane. Once the tension's released, then we know we're through the deep plane and we can go sharp or blunt. In a traditional deep plane lift, when we're entering this far forward in the face, blunt dissection's really, really easy. So you can see the orbicularis is coming up with me there. This is a TREPSAT disector. I also like the VITERBO disector you'll see in a different video. They are really good for blunt dissection. This traditional deep plane lift, entering from the orbital rim to the angle of mandible, as soon as you enter, you're in this loose SMAS and it's easy to bluntly dissect. Later on in the presentation, when I show you that we can enter more posteriorly, you can't use blunt dissection very readily to elevate the SMAS off of the parotid itself. It's too tight. All right, now here's the zygomatic ligament or at least the main portion of it. And we've defined the two cavities above it, below it. And now we're just taking the cautery or you could use a 10 blade or you could use scissors and releasing the zygomatic ligament, aiming the energy up at the flap. You can see the zygomaticus major's origin there. That's the inferior border of it. And I'm just releasing the zygomatic ligament to get freedom of the face. So traditionally, this has been what would be considered a pretty good deep plane face of going a centimeter or so down zygomaticus major. And then we'll take the same plane and cross the angle of the mandible and go down to release the platysma auricular ligaments. So the attachments between platysma and the parotid tail, platysma and sternocleidomastoid to get the neck to be mobile as well. So this is a pretty good composite deep plane facelift. I would not call it deep plane extended. What I consider as extended is what you'll see later when we take these attachments all the way down zygomaticus major to the motiolus. That's what I consider an extended lift. So now we're delaminating the skin from the platysma or the lower SMAS here. And we're making sure we go all the way forward and completely releasing any last remnants of the mandibular ligament that may not have been released at the beginning of the procedure from the submental incision. So with that, we've released the four major ligaments, zygomatic, masseterics, platysma auricular, and mandibular. Then we go ahead and set this in. You can use interrupted sutures. You can use running sutures as you like. But the idea is you're bearing all the lift on the SMAS. You're not bearing any of the lift on the skin. So this is a traditional deep plane facelift design, deep plane facelift execution. Now, in the last several years, this part's Andrew Giacono's calling card. We're getting better ligamentous release. We're not looking at the zygomaticus major or zygomatic ligament as a single point here at the origin of zygomaticus major. It's become clear that there are ligamentous attachments that run all the way down the body, zygomaticus major to the modiolus. And so we're riding zygomaticus major, not just a centimeter or so down, like most high SMAS or deep plane lifts do, but all the way down the face. That creates better mid-face mobility. The next innovation that really the last couple years I've taken on is to minimize subcutaneous dissection. And these ideas came from Mario Pelli and his lateral skin displacement neck lift. Ben Tilley does less subcutaneous undermining the vertical neck. Mike Roski's mentioned on the Telegram channel a year plus ago that he got sloppy sometimes on the second side of his surgery and left some dermal attachments between the platysma and the skin in the infragonial region. And he noticed that the sides where he didn't fully free it, he got better improvement in the submedieval region. And that only makes sense if we're pulling on the skin here from just under the mandible where it's attached to the platysma. We're using the platysma to carry the skin. It's a better way to carry the skin than to fully delaminate and control the skin from the occipital hairline. It's just like the deep plane carries the anterior face skin better. If we're leaving attachments here under the gonial angles between the skin and the platysma, we can use the platysma to mobilize the submental skin. Dominic Braes pushed this. So this preservation facelift term that I coined is for minimizing subcutaneous dissection and moving everything on the deeper layers in a very similar way that we're moving away from surface rhinoplasty techniques to deeper rhinoplasty techniques. The benefits are by minimizing the delamination in layer two, that's the layer that causes all the problems. So you minimize delamination layer two, you get less hematoma, less seroma, fewer phalangectasias, less ischemia. You get improved control of the skin of the lower neck. And it sounds counterintuitive, but again, we're gonna carry that lower neck skin on the platysma instead of separating it from the platysma and trying to just pull the skin on its own. Again, this parallels preservation rhinoplasty, there's immediate redrape, the subcutaneous tissues are less injured and therefore healthier and they look better and heal faster. So this is the traditional entry point for the lift with the surgery I just showed you. This is the amount of skin undermining that is required to create the space to do a traditional deep plane facelift. Now, if we take the entry point and push it posteriorly, Ben Talley's sailboat modification is similar to this. This is even more in terms of it's almost approaching a high SMAS entry point. If we push the entry point posteriorly, we only have to undermine a very limited amount of skin to reach this entry point. So it's decreasing the amount of skin undermining and increasing the amount of face that has traveled in layer four. So we're decreasing the layer two dissection, correspondingly increasing layer four dissection. And then we're going to leave skin attached to platysma here so that as we do the lift and as we take the platysma and lift it posteriorly, we're controlling the submental skin from this point instead of controlling the submental skin from all the way back here. Much better control of the submental skin. There is some submental undermining performed. That is done so we can get in and do the true deep neck work. So this is less subcutaneous undermining, but every bit as complete surgery as the previous. And what you're seeing here is a contrast between the green, that is the current amount of undermining I do, and then the yellow, which is what used to be done to achieve a true deep plane facelift. You can see here, this vertical section of the neck is left completely on the platysma and it gets better skin control. All the purple now is composite flap. So we are still operating across the entire face or neck. It's just we've converted more of it to composite flap and less to subcutaneous dissection. So this is what this dissection looks like. You'll notice it's a shorter skin flap. That's Pitangue's line. There is marked out the zygoma. And now we're opening this mass and we're doing the same thing, cauterion 18 to 20, and incising until we can see the tension released. And we know then we're in the potential space known as the deep plane or layer four. What I've marked out here is zygoma. And then down here, I've marked out the angle of the mandible level. So here we're at the angle of the mandible. Remember we're covered. The parotid is covering the branches of the facial nerve. They're sort of very safe. They don't become superficial until they exit the anterior border parotid. And then we're continuing this incision in the SMAS down to find the posterior edge of platysma. And we're gonna take that and undermine the platysma in the lateral neck. And the first centimeter or so anterior to the sternocleidomastoid overlying the parotid tail is dense and sticky and adherent. And you really need to do it either sharply or with a cautery. Same thing up here. This is SMAS that is further posterior than the traditional deep plane entry point. And so it doesn't spread very readily. Taking this up off the parotid, it requires energy or requires something sharp. Here we are coming further forward and you're just starting to see we're getting into the loose areolar region of the neck. We're getting anterior to the stickiness. I'm keeping this on a broad plane. And now we can see this is a Viterbo disector. I'm doing the same pre-zygomatic space dissection. I'm capturing a little orbicularis up into the flap. And I took this pre-zygomatic space dissection all the way to the side of the nose. And then we'll pack that temporarily because that orbicularis edge will commonly ooze. Now again, we're in the loose areolar region. We've come anterior to the edge of the parotid. So it's not sticky anymore. And we're using this Viterbo disector to do some blunt dissection. Here in the middle section, we're still fairly posterior in the face. And so it's sticky. It's not an easy blunt dissection. So I'm still using my cautery. And I'm just following the platysma on the top of the flap. I'm following the potential space, which is really evident. You can see it down the flap. Now we're following zygomaticus major. I'm taking my Viterbo and spreading down zygomaticus major. Whenever I feel like I can't spread anymore and it's getting sticky, well then I'll take my sharp dissection again, which I always use cautery for, and follow the plane. The plane is really evident. You can see exactly where the potential space is meant to be. And anything that's sticky, I take with a cautery. Anything that looks like it'll spread really easily, I'll switch back and spread it with a Viterbo or a Trepsat. One of the reasons I like the cautery, again, it's on 18, it's low energy. Here we go, we're spreading. You can see the platysma coming up into the line of decussation in the face. Spreading down zygomaticus major. Connecting across where it's sticky. One of the reasons I like the cautery is I can be forewarned as I approach any little nerve branches. And if I don't see any jumping at all, then I feel really good that I've done a really, really safe dissection. If you see something that you're not sure is a nerve branch and you touch near it with the cautery, it's kind of like the poor man's nerve stimulator. Don't touch the strand, touch adjacent to it and see if you get any stimulation. So now we're following or inferior to the mandible now, and we're releasing more in that sub-platysmal plane in the neck. And I've been much more careful over the years with making sure to do this mostly by spreading and then really looking for cervical branches like there's a cervical branch it's really obvious some of there are not so obvious and I release these little strands only as needed I do it with a cautery and again if there's something I'm not sure is a nerve branch I'll use the cautery on the soft tissue next to that strand and see if we see any transmitted stimulation there is the anterior border of the parotid there's parotid duct there's zygomaticus major the tension band you can see a little of the pinkness towards the top again parotid duct this is the buckle fat pad you can see showing just inferior to zygomaticus major you can go after the buckle fat pad there if you want I prefer trans orally there is the lower buckle trunk there's external jugular you can see it coming out inferior to the parotid tail and then I'm doing a little bit of a back cut of the posterior aegyplotism I will show you why later in the presentation that I sometimes like to do that so there we have it that's the extent of our subs mass dissection you can see how much mobility this is created so now we're going to take the cuff and we're going to this in this case this is 30 nylon we're going to use some sutures to inset the cuff into the appropriate vector wherever you get the maximal travel is the appropriate vector you could also do this with a running suture you could do this with dissolvable suture the last few years I've used nylon for this and I've had no issues with palpability no issues with extrusion and so that's what I'm sticking to you for the time being so we throw the knot we check to make sure that we haven't created any deformities or over tightened anything and then we'll go ahead and do each of these all the way up the side of the face and what you should notice is there's very very minimal subcutaneous dead space left once we have this flap inset and pretty much although we dissected all the way to the side of the nose and all the way the modiolus all that dissection was done deep to this mass so there's really no trauma in the subcutaneous plane that was the same video all right suture choice absorbable or permanent this is one of my own failures you can see where the SMAS flap was inset in the past and I reoperated on this woman thinking maybe the absorbable sutures gave way when I opened her SMAS inset was exactly where it was meant to be I went ahead and did another deep plane facelift on her open the SMAS undermined and you can see she's advancing again just as far as she did the first time so this was not a failure of dissolvable sutures letting us down her face just really was extremely elastic and we were able to advance this the second time so I don't know that this was a dissolvable suture failure but I have been using more permanent sutures in the face just just on the off chance that maybe they make a difference the buckle fat pad again you saw it in the deep plane dissection you saw where it's easy to access you can tell when the buckle fat pads part of the jowl because this full this is sitting well above the jawline this is the subcutaneous fat and SMAS contribution to the jowl this is the buckle fat pads contribution to the jowl and if you were to just tighten the lower face exceptionally well doesn't matter this buckle fat pad this part of the jowl will not get any better and anything as you tighten really strongly underneath it this will hang over even more and look even worse so here are a couple famous Americans that have had facelifts and you can see that their buckle fat pads were not addressed as a part of their facelift this is how you'd access it through the side of the face if you chose to getting the lateral mandibular definition really comes down for the most part to in the mid body the mandible sculpting the submandibular gland if someone's got prominence like this without sculpting the submandibular gland you can get great contour here where you're doing the interior neck work suppletism of fat work but then you'll have a bulge right here so the submandibular gland becomes critical to define the mid-body the mandible and then posteriorly to augment or to reveal a better contour in the gonial angle it's either subcutaneous fat sculpting after this mass has been inset the platysmal hammock can help or augmentation of the gonial angle so this is how we get the front section is the deep subplatysmal fat the middle section is the submandibular gland if applicable and the posterior section of the jawline is subcutaneous fat plus or minus platysmal myotomy or augmentation of the gonial angle now platysmal myotomy as my friend Andrew describes it he does a myotomy all the way down more than halfway down the body the mandible I think this is a double-edged sword so one good thing that happens when you do a myotomy that far down is you can take the neck flap move it dramatically more posteriorly than vertically on the face this can tuck under the jawline and emphasize the jawline shadow so I think those are the positives this is a good example of this this is one of my reoperations and you can see the platysmal myotomy that I did the negative is if you take your own hands hold against your jawline and lift straight vertically lift the direction that you would lift your facelift flap you can feel that that really tenses and tightens the submental region really well right but if you do that and then imagine a long platysmal myotomy right under the jawline the tension you're creating from the facelift that improves your submental zone is lost when you do this long platysmal myotomy right under the jawline and so I think that's a double-edged sword and I do very little platysmal myotomy anymore I do maybe a centimeter at the conial angle but that's it I don't do a long platysmal myotomy anymore once we have the face inset then we can either take the posterior platysma and inset it over the mastoid or we can do the mastoid crevasse which is Ben Talley's innovation what that is is finding the parotid tail lifting it up off of the mastoid tip and then insetting the posterior platysma into the anterior surface deep anterior surface of the mastoid tip the reason this is theoretically better is it allows us to move the platysma posteriorly superiorly and internally which someone with a broadly pneumatized mastoid you don't have that aspect of motion because the platysma would otherwise sit kind of lateral over that pneumatized mastoid so the benefit to this if you do it is you might be able to create a little more posterior conial angle contour the negative is when you manipulate that parotid tail once in a while you'll get a sialoma and so you saw me put a little bit of neurotoxin in the parotid tail to decrease the odds of that the other thing I sometimes have an issue with this is sometimes I feel like the vector of lifting the platysma to this mastoid tip anterior surface it's kind of too vertical and sometimes the neck I want more of a posterior vector in the platysma so I don't do this every time but it's a nice innovation and and you know Ben says he does visit a hundred percent of the time and I fully believe him in my circumstances I'm down to about fifty percent of the time now because sometimes I really want to see that platysma come more posteriorly than superiorly so as we're doing this procedure this is the starting dead space as I talked to you about it used to be everything in yellow nowadays I start with only the green but by the time you inset the SMAS and platysma the only subcutaneous dead space left is this little little green area so very little subcutaneous space at the end of the surgery is remaining so in my career when I first started out I was anxious about elevating in layer four about about dissecting a layer four because the nerves are there the vital structures are there and so junior surgeons tend to want to spend most of their time in the subcutaneous plane and minimize deep plane dissection as you get further in your career you realize that the subcutaneous plane is the plane that comes with all the miseries and all the complications that you have no control over hematoma seroma ischemia telangiectasia all those are layer two phenomenon so you realize that if you are in layer four and everything moves the next day their nerves are intact everything's fine there are very few delayed complications the more time you spend in layer two the greater the chance of delayed complications that you don't have great control over so the safest plane over a career changes initially you feel like it's the subcutaneous plane now I definitely feel like the safest plane is the submuscular plane and I want to stay out of the subcutaneous plane as much as possible the other interesting thing with having the subcutaneous dead space be this small is that I trust this type of dead space closure to glue I don't feel like I need drains anymore also it would be hard to put drains in these small discontiguous spaces so I since I started doing this preservation technique I have stopped using suction drains in the face I still use them in the brow so this is what the closure looks like is we after we irrigate everything out we take some sponges and you want to create a very dry surface so that the fiber and glue really works and then we use an atomizer and spray and artists which is like to seal but it's thrombin concentration is only one tenth of two seals thrombin concentration so it cleaves the fiber antigen more slowly and you have more time to lay the flaps in any directions that you want and get a couple chances so it drapes perfectly and then this helps the flap it here and it decreases the chance of seroma some say it decreases the chance of hematoma but it it makes so you don't need suction drains and the patient still doesn't bruise and still doesn't get seromas so that's then after insetting the flap and lasering etc but the fibrin glue on these small subcutaneous dead spaces has been perfect as an alternative if you can't get fibrin glue or if it's too expensive you can use the ours vault net this is a video from Andrea Oswald and what the ours vault net is doing is taking the skin and tacking it down to the foundation using suture it just goes through and through and through and you would do this suturing anywhere you do layer 4 suture so this is what it looks like you're going through the skin anyway you have layer 2 undermined pardon me you go through the skin capture the deep tissues and come back out and this this closes off the layer 2 dead space so if you don't have fibrin glue available you could use ours vault net sutures instead to close the layer 2 dead space I don't do this routinely I do it only if I don't have fibrin glue let's say I'm on a trip teaching trip somewhere in another country and they don't have the glue or if a patient is particularly bloody well then I'll use this on a particularly bloody patient we leave this in two to three days they don't leave any marks if they're taken out in that span of time you can also do a targeted ours vault net just a couple couple tacking sutures here and there to control drape results wise I'm going to show you just a few of them because many of you've already seen results on Instagram etc but these are all deep plane facelifts deep neck lifts so far these are the traditional deep plane facelift technique that I'm showing you where I entered anteriorly from the angle of mandible to lateral orbital rim a lot of these are combined with other procedures neck rhinoplasty etc now this one is a preservation deep plane facelift and what I mean by that is the vertical section of her neck skin was not undermined off platysma at all and a good island of non undermined skin was kept intact here and inferior to the gonial angle so that when we do the composite dissection lift her smash posterior lens superiorly the vertical neck skin comes along passively and the submental skin is captured really well so one of the reasons I'm showing you this early example is you can look at her Sun damage look at the redness it's all the way down here at the cricoid level and it has been expanded and stretched all the way up above the thyroid level because the skin has been lifted so effectively with the platysma you'll see that again from this angle the redness is down at the cricoid or even lower and now the redness has been stretched out and lifted and it's up over the thyroid level you can see it really well on the side view again track the redness it's come up over the thyroid this white band has been compressed there it is again you can see the whiteness on the front of her neck has been lifted and compressed all the way up to here pretty dramatic improvements this is one week post-op this is seven or eight months post-op and you can see the shape is still very well maintained even though the dissection the subcutaneous layer here is much less than I've ever done and I think this is a real advance you can actually see there's the white piece that corresponds right there and used to be this big large area it's been compressed and it remains compressed up there the neck has lifted so effectively this is another patient I did this patient for the MCAS Congress she has incredible skin skin damage and so I often get asked well what about patients that have a lot of skin damage a lot of Sun can you do a preservation style lift on them or don't you need to completely skin their necks completely delaminate their necks and Mario Pelli Cerebellos LSD platysmaplasty was where I came up with this concept he in that procedure does not delaminate the skin from the platysma here because he's using the platysma to control the skin and so we've incorporated that into this preservation facelift style procedure and this person was done with the very limited undermining that I showed you in all the diagrams this is her post-operative day one so the vertical neck was not undermined off the skin at all only a small island under the chin and a small cuff around the ear was subcutaneously undermined the rest was all deep to this mass or deep to the platysma and you can see how this skin has been lifted up and stretched out because it's being carried by the platysma itself that's her post-op day one here's a few months later and there has been no resurfacing done here she had a VI peel a very light chemical peel of her face but no peeling or resurfacing of the neck and no delamination of the neck all of this skin improvement was carried by the platysma so she did have a very light resurfacing of the face but nothing below the jawline she had my minimally invasive non endoscopic brow lift deep plane extended facelift and the preservation style minimal skin dissection and then the neck deep neck lift with minimal skin dissection and this is a person with really really sun-damaged skin and I think this shows that yes this procedure can be used very well on people with sun-damaged skin men I like this procedure a lot in men men tend to bleed and again layer two is the layer that causes all the issues this is a couple months post-op we want to keep ourselves out of layer two as much as possible especially in men here he is at a week post-op a couple months post-op dramatic dramatic improvements and we're staying out of the out of the trouble layer out of layer two here is several months post-op another lady with really really bad skin I think you get the picture this lady is a very very thin skinned person extremely thin skin person and she is a good example of why I sometimes want to back cut the platysma at the posterior edge because you can see when I lifted her up really strongly it improved her neck but it created tension at the posterior edge of her platysma that was really not there before and had I done a little posterior back cut from the lateral access from the face of flap I think we would have avoided that you can see it again here so that's why nowadays I sometimes do this little back cut that I was showing you where I cut the posterior edge of the platysma if I think this might be an issue for this patient so in summary first we rebalance the volumes of the face and neck that creates the foundation second we get full ligamentous release and by full ligamentous release it's not just the four traditional ligaments that we talked about but all the way down zygomaticus major to the modiolus third we're expanding how much of the surgery done through a composite dissection instead of a subcutaneous dissection so we're preserving composite flaps as much as possible those are what's creating the prettiest looks that I can create today so I want to say thank you this is my staff I want to invite you again to join the telegram group if you are interested in face of surgery if you're just starting out it's a very welcoming environment people people really answering questions and sharing videos and articles and experiences if you're an experienced facelift surgeon I would really invite you to join because it's it's just a wonderful thing to mentor other people thank you so much for having me speak I was wondering how often do you open up the neck centrally very rare in my case I think we we have I have my patients not so strong not so heavy neck but when when I have very heavy neck I I open and treated it to be under the platysma I do a deep neck and I can treat I can treat everything here but normally and my philosophy and also regarding anatomy when I cut very low the platysma laterally and pulling up this part of the platysma very high over here above the mandible above the mandible angle you can do a strong strong lifting of the platysma I don't go with this to the to the to the mastoid fascia but I I go up so I'm going to show you during my presentation that and this distance is like five or five centimeters up okay if you do like that you can mobilize here you can put back the the submandibular glands and improve a lot the neck okay so um so and my understanding from your presentation is that you make a cut in the platysma about three centimeters below the mandibular far three to four centimeters below the mandibular line very slow and then I elevate the platysma from here to there okay and how far along uh medial three three three centimeters and mike you had um in your talk um um about your your change in your technique for the neck could you talk more about it yeah so um I still do all the deep work the same largely I got a lot of it from Tim Martin and then Andre made it better so Andre thank you very much um the the initial step is to create space to drape the SMAS into skin into so if you don't have adequate space to drape the SMAS in the skin into then it becomes very difficult to get a beautiful result in the long-standing result that natural result and that's uh through canal through Tim Martin and then Andre and Jerry are Jerry O'Daniel have pushed that significantly further um but so creating space so that's the deep structure whether it's the level 1a fat the uh submandibular gland access the gastric access perihyoid fascia um in Andre's case strap muscles which is amazing but we create create a structure first the changes in the last year and a half or so for me have been not delaminating the neck nearly as much as I used to um as with the deep plane face we enter the SMAS plane and then carry the skin of the interior face on the SMAS and we get a powerful redraping of the interior face skin without delaminating it from the SMAS cuff similarly by leaving the vertical neck skin attached to the platysma and interestingly leaving I call this Roski's patch because the guy named Mike Roski's in Canada came across this accidentally when he was sloppy with the dissection of the skin under the gonial angle lifting the lateral platysma he found he got better control on that side whatever second side was kind of sloppy he got better control of the submental skin on that side um because you're leaving the fibrous septal attachments attached between the lateral platysma and the skin and scenario controlling the submental skin from here instead of controlling it all the way back from the occiput and so it cuts in half the distance the you know across which the spring force activates or the spring constant activates and so by leaving the skin attached to the platysma low leaving the skin attached to the platysma under the gonial angle when we do that lateral platysma lift into the space that we've created I personally get dramatically better results submentally and on the vertical skin of the neck like it's exactly opposite what I used to do which is maximal delamination so it's less time dissecting less time hemostasis and just like we get better results here when we carry it on the SMAS I'm getting dramatically better results in the submental skin and vertical neck skin carrying it on the SMAS. Okay and when uh for the midline are you um placating platysma bands because wouldn't that bunch the skin up this way or or not so much? So I've done many things right now for 90 percent of people what I'm doing is after I elevate the platysma flaps and do the deep sculpture then I'll take the platysma flap and this is an important step that I that I underestimated I'll take the platysma flap pull it across midline and this is again Bruce Connell basic stuff pull it across midline and take whatever excess crosses midline pull the opposite flap across midline take whatever excess crosses midline and just do a simple closure a little bit below the the hyoid and a very limited backup. I found if you don't take the platysmal excess you don't get as quite as tight of a cemental plane. If you do a Feldman necklift true multi-layer running vertical mattress invaginating suture that really does anchor the face low and forward so there's kind of a balance you want to take whatever excess there truly is but you don't want to have tension pulling medially and inferiorly. Okay so I imagine you're doing that placation first prior to doing the lateral. Yes especially because if you leave the five receptacle attachments from the platysma of the skin laterally when you do the lateral lift it becomes actually very difficult to get into the cemental pocket which is it makes you feel good at the end of surgery because it's not distensible you feel you feel good about it at the end of surgery. But it would be hard to do surgery at that point be hard to do significant cemental surgery at that point. Yeah when you're doing your submandibular gland dissection do you suture the anterior digastric together to make the gland more medial? I generally don't I rely more on digastric excision. If after digastric excision I still have fullness in the central submental region then I'll do a digastric tendon placation and muscle placation but I don't do it as a first step it's more of a secondary maneuver if I can't get the platform through excision. Okay and so Dr. Oswald so with this this less delamination so then I guess there would be less need for hemostatic net sutures or less ability to put them in? Well I do most of the things that Mike does in terms of the bulk in the neck. We consider the bulk top priority for a long-lasting result for neck surgery. If you open the platysma and look under the platysma you're going to see most of the case in large or ptotic gland and digastric hypertrophy and sometimes displacement of the hyoid. So in my perception treating these deep set structures is the most priority step that we take into our practice every day. We remove part of the gland in most of our patients. I would say that over 90% of our patients with the bulk the deep set structures like sumandibular salivary gland with resect the digastric but we do placate in the midline. I've been doing this for a long period of time. With this I can reposition the base of the tongue. For instance today I operated on a patient that has a huge tongue. Most of the surgeons don't look at the tongue but the tongue is the roof of the neck. Okay if you see a MRI you're going to see that the tongue the base of the tongue is part of the neck. How can I reposition the base of the tongue? So in my perception and in our experience we remove the digastric and we placate this digastric the residual part of the digastric in the midline. With this I can reposition the base of the tongue. It's really very efficient in terms of making a more well-defined cervical mental angle. Beside that that's something that I do different from Mike but I know that he has a huge experience so am I so do I. I delaminate because I want to remove you know the lower part of the sagging skin and delaminating the the skin down to close to the to the clavicle. I can redrape the skin superiorly and it's very effective. So I think well what I would say in terms of cervical contour the bulking is the most important part. In terms of redraping the skin I know that Mike has his own perception I have my own and Ruth has her own perception but what I have been doing for a long period of time maybe for the last almost 20 years redraping the skin has been very successful in our practice removing more skin from the lower part of the neck which is a very important part of the neck. If I transect the platysma at this level I know that this area here can become more loose you know you transect the platysma we believe that the sagging platysma in the lower part which is a very important part I would say that 60% of the neck is vertical only 30% of the neck is horizontal. We are addressing more the horizontal part and not the lower part of the neck. With this approach that we do we can you know address the entire neck 100% of the neck. That's my perception but I know I have seen I have followed you know Mike for a long period of time and he has shown great result maybe all roads leads to Rome. And what percent of time are you reducing submandibular glands Mike? Similar to Andre I would say 90%. If there I err on the side of doing it because when you then create the SMAS platysma redrape if you do any said at the end of the case almost always doing some subcutaneous defatting as they age a little bit and become a little more lean if there is any submandibular gland hanging beneath the border of the mandible they come back. And it's not a minor revision at that point so I err on the side of doing it every time. So 90 plus percent exactly like Andre. Are you both or all three of you injecting Botox into the the stump? I do if I can see it. Sometimes the stump is retracted so far behind the body of the mandible you can't get a direct view of it and I don't in that case. But if I can see it I do. I actually use Dysport. I do about 20 units of Dysport just because actually one of the guys on my telegram said well doesn't Dysport set in more quickly? I'm like well yeah and actually the goal is to get that gland shut down as quickly as possible. So I use Dysport. I use Botox instead of Dysport now. Okay good point. Well Mike what's percentage of the gland are you removing at this moment or have you made any change during along your experience? I can't say I can't say in terms of percentage. What I would say is there's two decision points. One the definite the minimum is everything that's below the axial plane of the body of the mandible. That's the minimum but sometimes that's the greatest dimension of the gland. Sometimes that's the equator of the gland and it's you know I love my ligature it's hard to get the ligature around the equator of the gland sometimes. So in those cases it's often more efficient to come further up towards the North Pole of the gland where the gland becomes narrow and resected at that point. And I've never seen it I don't think there is such a thing as a concavity and over resection of the lateral submandibular contour. So if the gland is really wide at that point I'll often chase it up higher to where it becomes easier to get across it and take it there. But whatever at least whatever is below the body of the mandible whether that's 10% or 60% it varies on how tautic the gland is. The ligature does make it easier to resect the gland. Does anyone else use it? Yes they do but not often. I started my practice resecting with the cautery so I'm using it to do that but sometimes I use ligature and I think it's a great tool especially for those that are starting with the deep necks or submandibular salivary gland resection. This is safer. You know the learning curve is much faster with the ligature. Yes. I actually the cautery is I used to use the cautery for years too and I would actually say it's in some ways easier because you don't have to you don't have to over dissect the capsule to get it around there you get to plan of resection and you can dissect through it. With ligature you almost have to over dissect enough to get the clamp up and around the gland but I just do it I had one delayed bleed when I used the cautery method to do it I was using monopolar cautery. I've had zero delayed bleeds on ligature and I don't know if it's I mean it's not enough numbers to make it statistically significant but the it makes me feel safer to have impedes controlled fuse the vessels together instead of coagulating with char. So when you are dissecting I find for myself and that I push it forward with my thumb or some you know some fingers so that I can visualize it better. Do you need to do that or you're able to see it pretty easily? It just depends on the patient. Often weirdly it shouldn't help but pressure lateral on the lower cheek sometimes help deliver it even though there's a bony wall in the middle I don't know why I could sometimes see it better. A one-inch malleable my favorite instrument is the and I learned this from Tim Martin it's a one inch malleable and so when you put it in the submental incision and turn it sideways it both it's long enough that it gets to the all the way to the posterior depending how you bend it it gets all the way the posterior aspect of the gland and it's wide enough that it holds the submental incision open and I don't put the submental incision posteriorly I know it's it's there are benefits to putting it posterior I put it in the crease so to have it held widely open is helpful so an army-navy is not wide enough or long enough to get into the capsule and hold the incision open at the same time a one-inch malleable bent a little long is my favorite instrument for that. I think one of the most important step for those that are starting their learning curve in the training the submandibular salivary gland is open widely the capsule once you open the capsule you expose the gland then you are safe the most frequent mistake that I've seen among our colleagues that are starting we just put a cadaver workshop this weekend here in San Paolo and I explained them and then we went to the cadaver and most of the surgeons were not opening the capsule sufficiently to be safe when resecting the gland because if you have a bleeding especially if you're with the cauteric not with the with the ligature then if you have a narrow space or a narrow tunnel you may get in trouble to cauterize these vessels because they are they can be very you can get intense bleeding from these arteries if you're cutting with the country but if you're with the ligatures you're not going to see any bleeding at all so it's going to be very easy but for those that are starting with the country I would recommend to open the capsule widely so you have control if you get any bleeding it's easy to suture over the gland or maybe spot the vessel and cauterize it so Mike are you doing the the posterior parotid mastoid crevasse that Ben Talai is doing or are you doing anything to augment the gonial angle I used to do a lot of fat grafting the gonial angle I hardly do it anymore my fat grafting in general has has decreased in the last probably three or four years the better you get it lifting I think the less fat grafting you need because you start taking some of the product fastening it back in the anterior face and reposition it on the male ornaments repositioning the gel fat onto the gonial angle and so you get you get auto augmentation which is kind of nice I did the mastoid crevasse in every case for a year or two probably and it's a fantastic technique that I have not been very good at there's be 100% honest with you there is one vector with the mastoid crevasse that's to the anterior face of the mastoid and if you have a short platysma or if the vector I just like with the with a deep plane face you'll inset the suture into the cuff and then you you judge what the optimal vector is to get the face to drape max mobility beautiful shape I have the same issue with the the posterior lateral platysma I tried it for a long time I could not get the results Ben gets in Dominic Ray and the UK gets him using the crevasse every time I had many where I feel like either I couldn't get the the reach on the platysma and I'd have spanning suture or I would have the vector is too vertical and I wish it was a little more posterior and because you get one choice the vector of the crevasse and so what I've gone back to taking my smashed excess creating a transposition flap again a la canal and then you have lots of length and you can I cut the transposition flap the inferior limit it down to below the gonial angle so that the tension is placed under the gonial angle not not over it so you can maximally define there and then take my forceps and I play with the vector until I get the maximal drape just like I do with the vector of the facelift so I'm basically treating the neck in a non delamination and the vector control the same way we do the deep plane face it's been really nice the one thing I'll just mention that they asked it but to get the debulking of the subcutaneous fat now we're trying to leave the five receptacle attachments together I am right between the platysma and the skin so I can keep control of the skin from here but we're not dissecting here so a fine liposuction can go at the end after I've done the entire case I'll take a 1.6 or 2.0 millimeter liposuction cannula and do the subcutaneous defatting which still leaves the five receptacle attachments attacked intact but I can get the the last bit of sharpening of the bony label that no with the last delamination are you still doing or are you doing a cut into the platysma to get one vector going vertical another going posterior or lateral so there's there's the the X the SMAS access gets turned into an inferiorly based kind of pennant flap okay okay so that's the cut and the inferior limit of cut stops just below the bony label so that way I have your vector on the platysma and what independent vectors I should say on the inframandibular SMAS and the supramandibular SMAS they go different vectors depending on what's necessary okay okay and I guess doing that sailboat modification is giving you a little more SMAS to play with it's Ruth were you gonna say something I just I think that you go back here but I I go more like this and then to the inferior part of the platysma I go to the to the mastoid area so I elevate more the platysma from here to there more than do like this but do more this and then the inferior part I go to the mastoid area I think I can get a better jawline and more more projection here to the angle and I agree with you that I do less and less fat injection in the face because when you work at the deep plane we open more proximal and then we can elevate better all this part here and then you improve much better the nasal labial fold the marionette lines the jaw and then you don't need too much is a fat anymore it's amazing how it's changing well a lot of that a lot of the volume deficiency here is actually sitting right here to answer your question sir it's almost if you think of a high SMAS dissection so it's not just the sailboat it's almost a high SMAS entry and then when you reposition it the excess mass becomes a transverse it's exactly it's very similar to what I smash when you open this mass more proximal you pull in this here you cannot go back you don't open here like a high SMAS or SMAS flap you open here but the deep plane you open more proximal so you bring this part there then you cannot reach the back of the ear okay all right thank you and so Andre are you doing any modifications for getting some gonial angle shape yes sure yes we do have our personal approach which is different from this lateral traction of this mass we don't separate this mass and the platysma from this from the sternocleidomastoid so we save these connections and we placate in the midline we don't do imbrications like Feldman has proposed on his corset descriptions so we resect the excess platysma in the midline and we just approximate in the midline from the chin to the sternal notch okay so we tension we don't transect we don't release we keep the platysma intact the full platysma is intact at the end of this placation when I go to the lateral aspect of the neck so I don't have to I don't have platysma to be transfer or pull it to the mastoid so it's already tension with this we can enhance the appearance of this sternocleidomastoid it's amazing what you can get with this approach I have been doing this for a long period of time so we cleaned all the platysma fat on top of the platysma on top of the sternocleidomastoid and this groove it's it's it's fantastic what you can get when you bring this platysma superiorly with the first sutures to the parotid masseteric fascia and in many patients maybe 50% of our patient we resect parotid glands so we can improve the elongation of the jawline superiorly up to the tragus so it's it's amazing it has changed a lot more my results I'm very happy with that without transecting the platysma without releasing the cervical retaining ligaments we keep the full platysma intact it's a different way I know this is not there's on there is not only one answer for treating the neck but we are very happy with it and I can well maybe show some one day you have seen from my talks my presentations what I have obtained with me my our own approach without releasing platysma ligaments without releasing transecting any part of the platysma we keep it intact okay that is very different thank you it's new but it's it's it's not very new I would say the difference from Feldman is that Feldman would imbricate and you may get maybe in a few patient that core medial core here so the way that we do we can control maybe 80 to 90 percent of the anterior platysma bands you know the hypertonic bands I cannot control the lateral hypertonic bands but you know when I do this application the lateral part the sort of diminished reduces the strength of this lateral platysma band but medial platysma band I can't control it it's impressive so are you all having your patients do Botox for maintenance of their neck results or recommending it can you see them please oh I said are you having your patients do Botox injections to maintain their neck no I don't don't need Botox in the just with the core set of the platysma and lateral pool can do just a line of suture in front of the sternocleidomastoid you know we focus on sternocleidomastoid rejuvenation it's one of the Ellen Bogan's criteria there are five criteria one of them is sternocleidomastoid rejuvenation so we really address the sternomastoid you know with this different approach we don't bring platysma over the sternocleidomastoid we remove the platysma from it okay okay well thank you all for joining me and I really am I'm so appreciative of your talks and your time and I'm very thrilled to be here with with all of you live so have a great evening you

Facial Aesthetics

Panel Discussion

Facelift Techniques

Neck Rejuvenation

Surgical Anatomy

Platysma Muscle

Deep Plane Facelift

Hemostatic Net

Neck Lift

Facial Anatomy

Nerve Injury

Submandibular Gland Reduction

Jawline Enhancement

Personalized Surgical Approaches

Anatomy Knowledge