Closed platysmotomy: a new procedure for the treatment of platysma bands without skin dissection

Abstract

Platysma muscular bands are present during the aging period, generally starting in the second half of the fourth decade of life in both sexes. One or two bands along the anterior segment of the neck are the most frequent, with varied extensions and appearances. The literature records different techniques for solving the problem of platysma bands. All the methods involve submental incision, cutaneous dissection, and various tactics for eliminating the action of the platysma bands. This report aims to describe a procedure for deactivating these bands using a percutaneous approach that eliminates the need for submental, cutaneous incision and dissection. This technique involves the use of a steel wire loop that encircles the platysma band and is connected to a device known as the platysmotome through two puncture holes in the skin. Three to six sections along each band eliminate the platysma band, leaving no visible marks on the skin. This method is indicated as an isolated procedure for patients with visible platysma bands and no skin flaccidity, patients with recurring bands after face-lifting and no cervical skin flaccidity, patients who have bands with little cervical skin flaccidity but do not care to undergo face-lifting, and patients who undergo face-lifts for platysma bands that include closed platysmotomy and tightening of the platysma by lateral suture. The described technique is a method specifically designed for deactivation of the platysma bands that can be used both in isolation and in conjunction with face-lifting. Because this method avoids submental, cervical incision and dissection, it is a less invasive technique for "deleting" the bands, whether applied alone or in association with face-lifting. From May 2008 to November 2009 (19 months), 61 patients underwent surgery for the correction of platysma bands via percutaneous myotomy. Among them, the first 11 patients received postoperative follow-up evaluation ranging from 8 to 17 months.

Fig. 1

(a–c) The platysmotome is a hollow metal cylinder with a solid cylinder inside that can be turned by a handle at the lower end. On the opposite end, a semicircular metal plate with a 1.5-mm hole in the center is attached to the cylinder, which envelops the turning rod. Two metal rings are attached to the external cylinder, by which the surgeon holds onto the device. Both ends of the wire, looped around the platysma band, are threaded through the central hole of the semicircular plate. They then are inserted separately through each hole in the solid cylinder and knotted. When the handle is turned, the wire loop is wrapped around the end of the movable rod, gradually pulling the loop, which cuts the muscle and then emerges from the skin. The simplified platysmotome (d, e) consists of a 2-cm-diameter metal plate with a central 1.5-mm hole soldered to a 12-cm rod at an angle of 140º (f, g). The two ends of the wire, after encircling the platysma band (represented in the figure by a tube of silicone), pass through the hole of the plate, which is resting against the patient’s skin. (h) The two ends of the wire are secured by a strong needleholder, which turns around itself. Its tail is a lever the surgeon uses to tighten it. The steel wire is wrapped around the end of the needleholder. (i) The loop is tightened around the muscular band, cutting it before surfacing through the point-like needle hole

Fig. 2

The platysma band myotomy proceeds through the following schematic steps: a The needle transfixes the skin and passes behind the platysma band before emerging from the skin on the opposite side. b, c The steel wire is threaded through the needle, emerging from the opposite end. The needle then is removed, leaving the wire in position. d The needle is reinserted through the first entrance point. By digital maneuvering, a space is created between the dermis and the space around the platysma band until the end of the needle exits from the opposite hole. e The steel wire is folded over itself to form a loop whose point is introduced at the end of the needle emerging from the opposite side. The wire encircles the band in a loop, with the two ends together and outside the first entrance hole of the skin. f The platysmotome plate, supported on the skin, receives the two steel wires, which pass through the central hole of the plate. The wires go through the respective smaller holes of the rod and are rolled around it, after which the excess wire is cut. The “butterfly” blades on the inferior end of the hollow cylinder are turned, which forces the loop to section the muscle and exit through the initial entrance hole. g Appearance of the neck before and after sectioning of the platysma band

Fig. 3

a Preoperative views of a 47-year-old Caucasian woman, with the platysma muscle contracted to provide a better view of the bands for skin demarcations. b, c Two longitudinal skin demarcations are made along the two bands. One side has five and the other side six transversal lines to indicate the number of myotomy sections to be performed. The outpatient surgery is performed with the patient under local anesthesia without preoperative medication. d–g The needle transfixes the skin behind the muscle band. The steel wire is threaded inside the needle tip and emerges from it, leaving the wire behind the muscular band and the two ends exposed. h–k The needle is removed and reinserted from the same skin entrance. It contours the muscular band and exits from the parallel skin puncture. The steel wire is again threaded through the needle to exit in the opposite direction, completing the loop around the muscular band. Light manual traction is applied to the wire to confirm that it has completed the loop around the band. l–n Both ends of the wire are inserted through the holes of the device and knotted. The excess is cut. o–q The device is placed gently against the skin with the wire ends protruding. When the handle of the platysmotome is turned, the metal loop cuts the muscle, and the wire emerges from the skin. It is important to realize that the circular plate, with the small center hole through which the two ends of the wire pass, is essential to keeping the wires held tightly together, preventing them from separating in the effort to cut the muscle, which could widen the puncture hole or cut the skin. Maintaining the puncture holes of the steel wire point-like is an indispensable condition of this technique because it guarantees rapid closure of the holes without scarring. r Final aspect of the neck. In this specific case, the central line of skin holes was used to treat both sides of the platysma bands. s, t An ice pack is applied for 15 min after surgery. u Final aspect of the neck skin after removal of the ice pack. v Another surgical option in which all the steel wires are previously transfixed to the specific sites on the platysma band

Fig. 3

a Preoperative views of a 47-year-old Caucasian woman, with the platysma muscle contracted to provide a better view of the bands for skin demarcations. b, c Two longitudinal skin demarcations are made along the two bands. One side has five and the other side six transversal lines to indicate the number of myotomy sections to be performed. The outpatient surgery is performed with the patient under local anesthesia without preoperative medication. d–g The needle transfixes the skin behind the muscle band. The steel wire is threaded inside the needle tip and emerges from it, leaving the wire behind the muscular band and the two ends exposed. h–k The needle is removed and reinserted from the same skin entrance. It contours the muscular band and exits from the parallel skin puncture. The steel wire is again threaded through the needle to exit in the opposite direction, completing the loop around the muscular band. Light manual traction is applied to the wire to confirm that it has completed the loop around the band. l–n Both ends of the wire are inserted through the holes of the device and knotted. The excess is cut. o–q The device is placed gently against the skin with the wire ends protruding. When the handle of the platysmotome is turned, the metal loop cuts the muscle, and the wire emerges from the skin. It is important to realize that the circular plate, with the small center hole through which the two ends of the wire pass, is essential to keeping the wires held tightly together, preventing them from separating in the effort to cut the muscle, which could widen the puncture hole or cut the skin. Maintaining the puncture holes of the steel wire point-like is an indispensable condition of this technique because it guarantees rapid closure of the holes without scarring. r Final aspect of the neck. In this specific case, the central line of skin holes was used to treat both sides of the platysma bands. s, t An ice pack is applied for 15 min after surgery. u Final aspect of the neck skin after removal of the ice pack. v Another surgical option in which all the steel wires are previously transfixed to the specific sites on the platysma band

Fig. 4

a Frontal, close-up, preoperative view of a neck with two long, separate platysma bands marked for the bands to be cut at four levels. b Immediately after the procedure performed to show the appearance of the skin, already described in the text. No face- or neck-lifts were performed for this patient

Fig. 5

a, b Views before the operation and 1 week afterward showing a 57-year-old woman with a medial skin band based on possible platysma muscular fibers interlaced along the medial line. The two platysma bands were treated and eliminated through four myotomies on each side. Skin quality shows minimal trauma and rapid recovery. c–h Frontal and lateral views before the operation as well as 3 and 17 months afterward. No face- or neck-lift was performed. There is minimal evidence of the platysma bands, even in this case with excessively thin skin

Fig. 6

a–d Left and right lateral views before the operation and 8 months afterward showing a 73-year-old woman who refused face-lifting in conjunction with a closed platysmotomy. Although the ideal indication for the case would have been face-lifting complemented by closed platysmotomy, we agreed to perform only the platysmotomy, considering the great hypertrophy of the bands, which the patient saw as a deformity. The patient underwent an isolated closed platysmotomy with five sections on the right and four on the left side. The outpatient surgery was performed with the patient under local anesthesia. No neck- or face-lift was performed

Fig. 7

a–f Three-quarter and profile views before the operation as well as 3 and 16 months afterward showing a 45-year-old patient who underwent a face-lift and closed platysmotomy with three myotomies per side. There was no incision or detachment of the medial neck skin. The lateral detachment was moderate, and only lateral plication of the platysma was performed

Fig. 8

a–f Lateral and profile views before the operation as well as 30 days and 15 months afterward showing a woman who underwent face-lift combined with closed platysmotomy. The two platysma bands were cut at four sites on each side. There was no submental skin incision or detachment