Best (Bolster Equalization Suture Technique) Neck: Optimization of Skin Redraping Following Necklift Surgery
Skin laxity of the neck is often a primary concern of patients presenting for facial/neck rejuvenation. Despite undermining, redraping, and excision of excess skin, central neck skin laxity often persists postoperatively. In many cases, postoperative garments will advance undermined neck skin centrally and shift skin flaps forward over the platysma, creating submental skin laxity. Overtightening of neck skin can lead to excess tension and result in wound healing problems and flap necrosis. Techniques such as external and internal quilting sutures have been described to reduce hematoma risk and more evenly redrape skin and distribute tension across the flap. However, there are significant risks to these techniques including flap ischemia, nerve entrapment, dyspigmentation, temporary dimpling, and added operative time.
In order to optimize skin redraping after necklift surgery while avoiding the aforementioned risks, the BEST technique was developed. The purpose of this study is to assess the safety of the BEST addition to necklift surgery, as well as the efficacy of eliminating residual central neck skin laxity.
Methods/Technique:
A prospective study was performed that included 20 patients undergoing facelift/necklift with the BEST procedure by the senior surgeon of this study. All patients underwent subcutaneous facelift with SMAS flap elevation, central neck liposuction, platysmal plication/myotomy, and partial anterior digastric muscle resection. At the conclusion of the procedure, three separate external quilting sutures were placed over protective bolsters to protect the skin from focal pressure of the suture. One bolster suture was placed at the subhyoid depression along the midline after smoothing any residual skin laxity. Laterally, the neck skin was redraped in a superolateral direction to accentuate the cervicomandibular groove. Then, below the angle of the mandible on each side, a bolster suture was placed to maintain the position of the redraped skin.
Bolster sutures were removed on postoperative day 5. Complications such as skin necrosis, skin ischemia, dimpling, hypopigmentation, hyperpigmentation, and scarring were documented.
As a control group, the last 20 patients who underwent the same surgery by the senior surgeon without the BEST technique were selected. For all 40 patients, preoperative and 6 month postoperative photographs were reviewed by two plastic surgeons blinded to the type of surgery performed. The photographs were analyzed for the presence or absence of residual central neck skin laxity, as well as the Rainbow scale for assessing the cervicomental angle. The degree of improvement of the Rainbow scale score preoperatively to postoperatively was analyzed for each patient in each group. All patients were surveyed using the pertinent sections of the FACE-Q, including perceived age, appraisal of the area under the chin, appraisal of the neck, and satisfaction with the outcome.
Results/Complications:
In each group, two patients (10%) had delayed healing of post auricular skin which resolved with local wound care. No other complications were noted in either group. There were no cases of skin necrosis, dimpling, nerve entrapment, hypopigmentation, or hyperpigmentation with the utilization of the bolster suture.
In patients who underwent necklift with the BEST technique, the median Rainbow scale grade improvement was 2 compared to 1.75 in the control group. Mann-Whitney U test showed that the Rainbow scale grade improvement in the BEST group and control group was statistically significant (p-value 0.016).
In the BEST group, 95% of patients had notable central neck skin laxity preoperatively and this persisted postoperatively in only 5% of patients. In the control group, 80% of patients had notable central neck skin laxity preoperatively and this persisted postoperatively in 35% of patients. This relationship did reach statistical significance with the Mann-Whitney U test (p-value 0.027).
Patient perceived age on the visual analogue scale was younger in the BEST group (mean of 11.3 years younger compared to mean of 8.8 years younger in the control group). However, results of the FACE-Q survey indicated no statistically significant difference between the BEST group and the control group when appraising the area under the chin (p=0.88), the neck (p=0.91), and satisfaction with outcome (p=0.88).
Conclusion:
The BEST technique is a straightforward, efficient method to equalize tension after necklift surgery and improve skin redraping. This may help reduce the risk of persistent central neck skin laxity which is often challenging to eliminate entirely with standard necklift techniques. In addition, the BEST technique helps to create a more defined cervicomental angle. The BEST technique provides improved neck contour with no apparent increased risk of flap ischemia or necrosis, dyspigmentation, dimpling/scarring, or nerve entrapment with minimal added operative time.