Feature: Exploring Aesthetic Interventions: Jawline Tuck for Neck Rejuvenation - By Emil Bisaccia, M.D., Liliana Saap, M.D., and Dwight Scarborough, M.D. This month’s article describes a “tuck” procedure for rejuvenation of the lower face and upper neck.   Recently, we have reviewed some of the more minimally invasive techniques for facial rejuvenation, including non-ablative lasers and suspension threads.1,2,3 In the next few articles, we will focus on more advanced techniques for facial rejuvenation such as jawline “tucks,” anterior “tucks,” midface lifts, full face lifts and neck lifting. Alhough more involved than the minimally invasive thread-assisted techniques that we have reviewed recently, the interventions described in these upcoming articles — including this one — employ the less-aggressive lifting techniques originally pioneered by Dr. Richard Webster. Dr. Webster, using a limited undermining technique and superficial musculoaponeurotic system plication (SMAS), obtained similar results with significantly fewer complications than the more traditional and aggressive deep-plane undermining lifts.4,5,6 This month, we describe a jawline tuck procedure for rejuvenation of the lower face and upper neck. Targeting the Sagging Jawline The sagging jawline is often the first sign of serious facial aging. Here we present an early intervention technique targeting the jawline to rejuvenate the lower face and neck. The jawline tuck not only restores the lower face and neck contour, but it can also improve mild platysmal bands alone or in combination with microliposuction and/or additional thread lifting to rejuvenate the face.1,3,7,8 Patient Selection The ideal patient for this technique is usually someone in the mid to late 40s or 50s with prominent jowls and blunting of the cervicomental angle and with some, but not an excessive amount of, redundant skin of the lower cheeks and neck. Those older patients with an excessive amount of redundant skin of the face and neck, as well as markedly prominent nasolabial grooves, may benefit more from the anterior tucks, midface lifts, full face lifts, and/or neck lifts that we will review in later articles, as well as the jawline tuck, in combination with ablative and nonablative lasers, fillers and Botox.9 As always, it is very important to assess the patient’s expectations during the cosmetic consultation to ensure that the best procedure(s) can be matched with both the patient’s expectations and needs, and that the limits of what each procedure can and cannot accomplish can be discussed with the patient. Materials and Methods Listed below are the materials required to perform our described jawline tuck. • Two to three 3-0 polydiaxanone absorbable sutures • Number 11 and number 15 scalpel blades • Blade handle • 4-mm spatula liposuction cannula • 60-cc Toomey syringe with Johny lock • Adsons forceps • Ragnell scissor • Needle holders • Allis clamp • Suture scissors • Towel clamp • Large curved Metzenbaums Method 1. The patient is marked in an upright seated position. Markings are done to delineate the area for undermining on the lateral cheek, upper neck and postauricular neck. The jowls and the neck are also marked for liposuction (Figure 1). It is imperative to have good knowledge of the anatomy, as the marginal mandibular branch of the facial nerve and the great auricular nerve can be vulnerable in this procedure. To minimize risk of injury, tumescent anesthesia and blunt liposuction are used in these areas. Figure 1: Patient with markings showing area for undermining pre- and postauricular and superior neck, and areas for jowl and microliposuction. 2. The patient is then prepped and draped. Supplemental sedation10 (depending on patient preference) is administered, then followed by local and tumescent anesthesia. 3. The procedure — step by step • Neck and jowl liposuction is performed through a nick incision in the submental area and in the periauricular areas with a number 11 blade. • Through these same nick incisions, the 4-mm spatula cannula is used to undermine the lower preauricular area, the post auricular area and the postauricular neck. • An incision is then made starting at the superior edge of the tragus (in the inner aspect of the tragus for women, and the preauricular cheek for men). • This incision is then extended around the ear lobe, continuing posteriorly 1 cm to 2 cm. • Metzenbaums are used to continue the undermining and release the tissue connections created by the 4-mm spatula cannula. • Subsequently, two to three plicating sutures are taken from the SMAS overlying the neck to the mastoid process. • Excess skin from the lower preauricular cheek, upper neck and postauricular cheek is removed and the skin is then sutured using 5-0 polypropylene. Absorbable skin sutures are usually not needed as the plicating sutures are placed in such a way as to minimize any skin tension. (Figures 2A to 2D and Figures 3A to 3D) Figure 2A: Area has been anesthesized locally. Figure 2B: Number 11-blade incision has been made and Metzembaums are used to slightly enlarge incision. Figure 2C: Tumescent anesthesia is injected to completely anesthesize. Figure 2D: Microliposcuction is done on neck. Figure 3A: Undermining with 4-mm spatula cannula. Figure 3B: Metzenbaums are used to complete undermining. Figure 3C: Plicating sutures are placed. Figure 3D: Incisions are closed and sutured into place.     4. After the Procedure The patient is placed in a facial garment and discharged with written post-operative care instructions, returning in 7 to 10 days for suture removal. Results We have applied this technique to more than 300 patients during the past 7 years with excellent results (Figures 4 to 8). Some patients have had the technique done alone, while other patients had it applied with other rejuvenating procedures, such as CO2 laser resurfacing, fat transfer, blepharoplasties, fillers, and Botox, among others. Figure 4A and 4B: Pre operative (left) and 8-weeks post operative (right) photos. Figure 5A and 5B: Pre-operative (left) and 2 months post-operative (right) photos. Figure 6A and 6B: Pre operative (left) and 6 weeks post-operative (right) photos. Figure 7A and 7B: Pre-operative (left) and 6 weeks post-operative (right) photos. Figure 8A and 8B: Pre operative (left) and 2.5 months post-operative (right) photos. Benefits The lower face and neck are often the first areas to show more serious signs of aging. Laxity of the skin and migration of the cheek fat pads can lead to prominent jowls and a loss of the mental angle. In patients with these changes, a jawline tuck combined with microliposuction can give excellent results. As mentioned, this procedure can be used alone or combined with other procedures to give optimal results. Unlike some of the more minimally invasive procedures, this procedure does involve some activity restriction (“down time”) of about 1 week to allow the usually mild swelling and bruising to subside. However, the results can also be more dramatic than other more minimally invasive procedures, while still minimizing the risks that have been seen with the more aggressive face lifts of the past. Risks Possible risks include bleeding, hematoma, infection, and scarring. Using the minimally invasive approach described, minimizes these risks. The very slight risk of mandubular nerve palsy is even less likely because permanent injury is avoided by using tumescent anesthesia, limiting undermining to areas marked in Figure 1 and using blunt cannulas for liposuction. The deep plane face lifting procedures can risk permanent injury to this nerve because of more aggressive undermining. Changing the Aging Face This jawline tuck — with or without microliposuction — is an excellent way to treat early to moderate lower face and neck aging. It can be done under local tumescent anesthesia or with intravenous sedation. It can also be combined with other procedures such as CO2 laser resurfacing, fillers, Botox and/or fat transfer to produce dramatic results customized to the patient’s needs.                   References 1. Bisaccia E, Kadry R, Saap L, and Scarborough D. Exploring aesthetic interventions: The thread-assisted jawline lift — a minimally invasive technique for rejuvenating the aging face. Skin & Aging. 2007;15(12):54-56. 2. Bisaccia E, Saap L, Kadry R, and Scarborough D. Exploring aesthetic interventions: Non-invasive procedures in cosmetic dermatology. Skin & Aging. 2007;15(10):38-40. 3. Scarborough D, Saap L, Kadry R, and Bisaccia E. Exploring aesthetic interventions: treating the sagging jawline and platysmal banding: a simplified technique Skin & Aging. 2007;15(1):50-54. 4. Webter RC. Conservative facelift surgery. Arch Laryngol. 1976; 102:657-82. 5. Webster RC, Brown CA, Hilger PA, Smith RC. Comparison between short and long term results in face lifts. Aesthetic Reconstr Facial Plast Surg. 1978;5:1-98. 6. Scarborough DA, Bisaccia E. The Webster-type face and neck lift: an extensive cervico-facial rhytidectomy employing a minimally invasive technique. Dermatol Surg. 2001;27:747-55. 7. Scarborough D, Saap L, and Bisaccia E. Exploring aesthetic interventions: The gold standard in facial resurfacing: the CO2 laser and future directions. Skin & Aging. 2006;14(10): 64. 8. Bisaccia E, Khan AJ, Herron JB, and Scarborough DA. Resuspension of mild to moderate jawline laxity using a minimally invasive technique. Dermatol Surg. 2003;29:810-816. 9. Jacob CI, Kaminer MS. Rejuvenation of the neck using liposuction and other techniques. In: Robinson JK, Hanke CW, Sengleman RD and Siegel DM, ed. Surgery of the Skin Procedural Dermatology. Philadelphia: Elsevier Mosby 2005; 691-701. 10. Bisaccia E, Scarborough DA. Anesthesia. In: The Columbia Manual of Dermatologic Cosmetic Surgery. New York: McGraw-Hill: 2002; 95-108. Skin & Aging - ISSN: 1096-0120 - Volume 16 - Issue 4 - April 2008 - Pages: 44 - 49