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Archive for the ‘submentoplasty’ Category

Plastic Surgery Case Study: Submental Rebound Relaxation After Facelift

Tuesday, December 16th, 2014


Background: A facelift is one of the most well known but also misunderstood of the anti-aging facial surgical procedures. Besides the frequent misinterpretation of what a facelift really is, there is also the confusion added to it by the marketing of many ‘franchise’ forms of facelifts which promise big changes with limited recovery. Numerous other minimally invasive to non-surgical types of lifts created by fillers and energy-based devices add to the mix of ‘facelift’ options.

Facelift Vectors Dr Barry Eppley IndianapolisBut moving beyond what constitutes a facelift are other important concepts such as the results and its short and long-term effects. Patients often ask how long a facelift lasts with  an understanding that it is not a permanent result. Like the onward march of time, aging will continue and the results of most facelifts will eventually be lost. (perhaps not completely but some of its effects will surely dissipate)

The most noticeable change will be in the neck and it should be divided into a short-term and a long-term change. The long-term change is obvious and refers to when one may return to what they looked like before the surgery. Estimates vary and no one number can factor in all the patient variables but the time frame of 8 to 12 years is often quoted. But a potential short-term change is often overlooked…a phenomenon known as rebound relaxation.

Case Study: This 65 year-old female wanted to improve her sagging neck and jowls. While the upper portion of her face had similar aging changes, these were not of concern to her. She stated that she did not look this way until about ten years ago when it started.

Necklift result Dr Barry Eppley Indianapolis side viewUnder general anesthesia, a full lower facelift was performed including neck defatting, platysmal plication and SMAS imbrication. Enough skin was mobilized back up over the ears that the entire ear had to be cut out from the mobilized skin redraping during closure.

Necklift result Dr Barry Eppley Indianapolis oblique viewNecklift result Dr Barry Eppley Indianapolis front viewAfter a full recovery, she had a great result with a fairly sharp cervicomental angle and no evident loose neck skin. When seen at six months after the procedure, she still had a very significant change but there had developed a small amount of loose skin or banding in the submental region under the chin. This was not an aesthetic concern to her not did she want anything done about it. She felt she had aged an ‘additional six months’ since the surgery.

Almost no matter how ‘tight’a facelift may be done, the ability of the result to hold is partially dependent on the elasticity of the skin. To no surprise, older aged skin has lost a lot of elasticity and will exhibit some relapse or skin relaxation afterward. This is usually seen in the submental region which is most distant from the point of pull of a facelift.(ears) These submental changes are not aging but a secondary skin relaxation phenomenon which is not usually seen until three to six months after surgery. Sometimes it does not become evident until about one year after the procedure. A submentoplasty procedure can be done to ‘touch up’ the facelift result and attacks this problem through direct skin excision.

Case Highlights:

1) A lower facelift works by a combination of removal and repositioning with the skin part being the most visible.

2) The vast majority of facelift patients want a natural looking result that is not oevrpulled or has a ‘windswept’ look.

3) Every facelift, no matter how much tissue removed, will undergo some degree of submental relaxation in the first six months after surgery. This should not be construed as recurrent aging or failure of the facelift. A secondary submentoplasty may be needed for optimal neck correction.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Submental Relaxation after Facelift Surgery

Friday, August 15th, 2014


Background: Facelift surgery is very common and is the single most effective procedure for correcting aging issues of the jowls and neck. By removing excess fat in the neck and jowls, tightening the platysma muscles and redraping loose skin up toward the ears and temporal hairline, a recontouring of the lower face is achieved. In every case of a facelift, the immediate surgical change is often dramatic and the more advanced the aging the more dramatic the change will be.

But no matter how a facelift is done, it has significant reliance on tissue pull particularly that of the skin. Because the skin is an elastic structure, there is always going to be some eventual recoil from the stretch imposed on it.  (not to be confused with eventual ongoing aging but a relatively immediate after surgery effect) In a facelift this is most commonly seen in the submental region. This point is exactly centered between the two sides of the pull on the sides of the face. Because it is so far from the area where the pull is exerted, it is the first facial area to show some ‘relapse’ as a result of this tissue relaxation phenomenon.

Case Study: This 40 year-old female wanted to improve her neck and jowl sagging. Despite that she was fairly young, her neck changes were more significant than her chronological age would indicate. She had fat and loss of her cervicomental angle. Her skin was also very thin and elastic which undoubtably made a contribution to her early tissue sag.

Limited Facelift result side view Dr Barry Eppley IndianapolisUnder general anesthesia, her submental and neck regions were initially evacuated of some fat by liposuction. Through a submental incision, the neck skin was widely undermined. A retrotragal preauricular and postauricular incisional approach was done around the ears to undermine the skin until it connected to that of the neck. Using a sutured SMAS plication technique done in differing vectors, the deeper tissues were lifted and tightened. The skin was then lifted and draped up over the ears, trimmed and the incisions closed.

Limited Facelift result oblique view Dr Barry Eppley IndianapolisHer four month facelift result showed a significant improvement in her neck and jawline. While the change could be called dramatic, some tissue relaxation had settled into the submental area under the chin. This was different that what was seen in the first few months after her surgery.

A suhmentoplasty procedure can correct the immediate tissue relaxation effects that can occur after many facelifts that have corrected significant neck changes. This can be done with with a crescent or an inverted T type skin excision pattern. It is prudent to advise patients that such tissue relaxation can occur and it is not rare. A submentoplasty for correction of submental skin relaxation after a facelift can be performed anytime six months to a year after the original facelift procedure.

Case Highlights:

1) Facelift surgery commonly undergoes some relaxation of the tissues as they heal and relax from the initial stretching forces.

2) Skin relaxation after a facelift is frequently seen in the submental and central neck area which is furtherest from the point of skin excision and pull. (ears).

3) A submentoplasty procedure may be beneficial six to twelve months after a facelift to ‘retighten’ the central neck area if any skin sag develops.

Dr. Barry Eppley

Indianapolis, Indiana

Fat Compartments in the Neck – Implications for Neck Contouring Surgery

Monday, May 5th, 2014


Neck Fat Removal Dr Barry Eppley IndianapolisFat in the neck is one of the major contributors to its shape. Large amounts of fat create full and/or droopy necks and work against a pleasing neck angle and profile. As a result, the removal of fat is part of just about every neck contouring procedure from liposuction to necklifts. The neck is usually defatted by liposuction at the supraplatysmal level but may also undergo direct excision at the subplastymal level in other neck contouring operations. (e.g., submentoplasty)

In the quest for optimal neck contouring and maximal fat removal, it is helpful to know where the fat compartments are in the neck and their contributions to the overall fat volume. This would help to understand what type of neck changes can be done and what procedures may be needed to fo them.

Neck Fat Compartments Dr Barry Eppley IndianapolisIn the May 2014 issue of the Aesthetic Surgery Journal, a study was published entitled ‘ Defining the Fat Compartments in the Neck – A Cadaveric Study’. In this study the anatomic compartments of the neck and their quantity and relationships were evaluated in cadaver heads by dissection. Supraplatysmal fat was found between the skin and the platysma muscle, and it was divided into suprahyoid and infrahyoid fat. Subplatysmal fat was found deep to the platysma and between the inner edges of the anterior digastric in the midline ad was also divided into suprahyoid and infrahyoid compartments. Lastly, the very deep fat below the anterior digastric muscles was identified as its own compartment.

Their findings shows that roughly 50% of the fat in the neck was in the supraplastysmal space. The subplatysmal fat accounted for roughly 25% and the remaining 25% was around the submandibular gland. The very deep fat was minute, accounting for only 1% of all neck fat.

Submentoplasty Dr Barry Eppley IndianapolisWhat this study shows is that the most commonly treated area of the neck for fat removal done by liposuction is the supraplatysmal space…and this accounts for only half of all neck fat. This means that many patients may not be able to achieve optimal neck contours with liposuction alone. In some cases the subplatysmal neck fat needs to be removed for a more significant neck contour improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Options in Contemporary Surgical Neck Rejuvenation

Sunday, December 8th, 2013


The neck, like the face, ages although it does so in a more simplistic fashion. With the neck it is only a matter of loss of the neck angle due to loose skin, fat accumulations and midline muscle separation. But with different degrees of neck aging at different times in life, the type of neck rejuvenation procedure that is needed changes. There are a variety of aesthetic neck procedures which include liposuction, submentoplasty, formal neck lifts (lower facelifts) and direct neck lifts.

Neck Liposuction Dr Barry Eppley IndianapolisThe reduction of neck fat by liposuction works best in younger people (under age 45 or so) who have good skin tone. One of the main principles of liposuction is that skin retraction is needed after fat removal to see its effects. However, in some older people with more loose neck skin that do not want a necklift, some good improvements can be seen with Smartlipo (laser liposuction) which does a good job with skin tightening. Liposuction in the neck must be aggressive (taking fat right off of the underside of the skin) to be most effective.

Submentoplasty Dr Barry Eppley IndianapolisSubmentoplasty is a less well known neck procedure for younger patients (under age 50 or so) that have both excessive neck fat and a loose or separated platysma muscle. Done through a submental incision under the chin, neck fat (above and below the platysma muscle) is done (by liposuction as well as direct fat excision) as well as muscle tightening/plication is done to create a more defined neck angle result. It can be a hard decision to determine who is best served by liposuction alone or whether the platysma muscle should be tightened after subplatysmal fat is removed by direct excision.

Facelift Dr Barry Eppley IndianapolisThe lower facelift or necklift, in the traditional sense, is for patients with more advanced loose neck skin/neck wattles/ turkeynecks (generally age 55 and older)  who need substantial neck skin tightening and resuspension. Most people aren’t that a ‘facelift’ is really a neck-jowl lift or a necklift. These are often interchangeable terms. But the concept of a facelift has changed…from the development and marketing of a limited jowl lift to a full blown extended facelift. Thus facelifts today can now be from as early as age 40 to any advanced age.

Male Direct Necklift Dr Barry Eppley IndianapolisThe most uncommonly performed neck rejuvenation procedure, a direct necklift, is done almost exclusively in older men . (65 years or older) Many older men do not want a formal facelift/necklift for either recovery or hairline concerns. It involves a direct excision of neck skin and fat as well as muscle tightening with the tradeoff of a midline scar. (which usually does quite well in the beard skin of men) Because of scar concerns, direct necklifts are not done in younger patients and rarely in even older women.

Dr. Barry Eppley

Indianapolis, Indiana

Necklifts for the Younger Patient

Sunday, December 2nd, 2012


While the face in theory ages evenly, one’s concerns about different facial changes is not. Besides the eyes, the neck is a frequent target of aging dissatisfaction. While the neck is composed of various tissues, one wants see is loose and hanging skin. This makes one yearn for the days when the skin between the chin and neck was firm and taut and a more defined neck angle existed. While styles and fashion have changed over the years, a sharp and clean neckline has always been a youthful image.

While the neck has always been a physical disdain of aging, what has changed is the age at which these concerns arise. Turkey necks and wattles are understandable neck concerns, but they represent older patients often in the sixth, seventh and eighth decades of life.  Ever since Nora Ephron’s book ‘I Hate My Neck’ was published, it was like a light bulb when off for many younger people.  Younger people, women and men alike, now appear in the fourth and fifth decades, to do something about their loosening neck skin. The reality is that the publication of the book was merely coincidental to this interest. The wide spread use of Botox and fillers has filled many a plastic surgeon’s office with early aging patients where the opportunity to discuss these concerns can easily happen.

The interest in addressing the earlier changes in neck aging has led to a variety of surgical and non-surgical treatments. A host of energy-driven devices exist for neck tightening, like Exilis and Ultherapy, but these are really bridging therapies until the time comes when one is ready for a more definitive surgical approach. Some fat shrinkage and skin tightening may work well for more minor neck droops, but really significant and and longer-lasting results requires tightening the muscle and skin to resist the never-ending effects of gravity.

Necklifting options today range from under the chin approaches (submental incisions) that use skin tightening caused by fat removal and/or muscle tightening and more traditional approaches (facelift) that use skin shifting and excision by incisions around the ears. Most younger aging neck patients are going to usually benefit by submental approaches and these are of the greatest interest because they are ‘less’ surgery with a quicker recovery. By definition a submental approach involves a small and inconspicuous incision right under the chin. It can be just a few millimeters when only liposuction is used. The heat created by the use of Smartlipo is a reall complement to the any fat removal done. For someone with a full neck but good thick skin, this could be all that is needed to create a better neck contour.

The most unknown necklift is that of the submentoplasty or platysmaplasty. Through a slightly larger submental incision, fat is first removed from under the skin but the cornerstone of the procedure is the muscle tightening. The sagging platysma muscles are sewn either back together or folded onto themselves in an up and down fashion creating an effect like a corset on the waistline. (which is why this procedure is also known as a corset platymaplasty) This shortens the vertical length of the muscle, pulling the neck angle upward  and with that the overlying skin as well. Other muscle innovations create slings from one side of the neck to the other using permanent sutures to create a hammock-like effect with special instrumentation for passing these sutures into the correction position.

While not as common, a few will have a neck problem that is not primarily fat but just loose skin. Skin laxity is a less frequent cause of younger patients but definitely becomes more of an issue as one crosses the half century mark. Loose skin in the neck, if not too severe, is managed by a smaller neck-jowl tuck-up or one of the many variations of short scar or limited facelifts. While less skin is removed than in a traditional facelift, the tightened on both sides of the jawline creates a hammock-like effect across the midline of the neck pulling it tighter.

The revolution in sagging necks is that more and more younger patients are turning to necklifts as stand alone procedures…changing for some the title of their own book ‘I Love My Neck!’

Dr. Barry Eppley

Indianapolis, Indiana

Options in Aesthetic Jawline Enhancement

Sunday, May 13th, 2012

The jawline is the defining feature of the lower face. It is quite simple from a structural standpoint being a u-shaped arc and serving as the transition between the face and the neck. But it can have lots of aesthetic problems that are extremely common complaints. A weak chin, a sagging neck, a double chin, jowls, and weak jaw angles are the main jawline issues that manu people have. Whether one is young or old, male or female, these jawline concerns can affect all due either to aging or a congenital structural defect.

The strong or well-defined jawline has become an important component of facial beauty and attractiveness today. With the advent of the internet and other electronic media, a new cultural standard for jawline aesthetics has emerged. Males contact me today and almost always point to the jawline of Brad Pitt and numerous less well known models as to their goal. Women similarly point to actresses like Angelina Jolie or Reese Witherspoon as their desired jawline look.

What makes up a pleasing jawline that conveys both attractiveness and a more youthful appearance? This always refers to a well-defined  and visible inferior border of the mandible that is straight from the jaw angle to the chin. The jaw angles are slightly higher than the horizontal position of the chin and there is a slight flare from front to back. The chin is more square in men than in a women whose chin is more narrow. Soft tissue that hugs the lower edge of the jaw makes for a well-defined neck angle and the absence of any jowls. It can be seen that the bone structure is the key to a good jawline which will also affect how the soft tissue may sag with age off of the bone.     

While I suspect a good jawline has always been a desired facial feature, many recent improvements and advancements in plastic surgery have made it more achievable. But there is not a single jawline technique that will work for everyone. A variety of bone and soft tissue surgical procedures exist and often more than one is needed to get the best result.

Chin and to a lesser degree jaw angle implants have been around for decades. But new improvements in implant shapes have made them more versatile and adaptable to a variety of jawline problems and are available off of-the-shelf. Chin implants that extend posteriorly to cover the prejowl area and those that have increased width to create a more square chin are but a few of the newer options. Better chin implant designs are still needed, particularly those that may allow for increased vertical as well as horizontal projection. Jaw angle implants have largely been in one style, that of adding more lateral fullness. But newer jaw angle designs allow for vertical height increase and stronger lateral flare as well.

But off-the-shelf chin and jaw angle implants can often not make for a completely straight jawline because they are not connected in the middle between the two over the central body of the mandible. Custom jawline implants can now be made that can create a central jawline augmentation that unites the chin and jaw angle areas. Custom designs may also be used when the size of the chin or jaw angles desired has greater dimensions that what off-the-shelf implants can achieve.

Soft tissue techniques for an enhanced jawline include a variety of well known procedures. Fat removal by liposuction, loose skin tightening and removal through differing facelift techniques, and neck muscle tightening can better redrape the soft tissues around the bony jawline. Two uncommon but useful soft tissue procedures are the submentoplasty and the direct necklift. A submentoplasty works best in the younger patient with a full neck where extensive fat removal and muscle tightening are done without skin removal. In contrast is the direct necklift which is for the much older patient who is willing to accept a neck scar for neck wattle removal and platysmal muscle tightening.

Contemporary jawline aesthetic surgery is more than just a chin implant or a facelift. It needs to consider all anatomical elements and combine a variety of bony and soft tissue manipulations to get the best lower facial improvement.  

Dr. Barry Eppley

Indianapolis, Indiana   

Non-Facelift Options In the Aging Neck

Friday, March 16th, 2012

An improved neck shape is a desire for many aging men and women. With time, loose skin and sagging fat develop that create a full neck with a more obtuse angle. When seeing patients who seek a better neck and jawline, they are usually surprised when the concept of a facelift is presented. They may have come in for a ‘necklift’ or some other limited operation but they most certainly didn’t think they needed a facelift.

For some, the issue of a facelift vs a necklift is a matter of misunderstanding terminology. It is common that most people believe that a facelift alters everything from the forehead down to the neck, not just an isolated neck and jawline change. Once explained properly they are ready to proceed with what they called a necklift. But for others a facelift is simply more than they want to do even though it is the ideal procedure for their aging neck and jowls.

Besides a facelift, they are a variety of other smaller or less extensive procedures that can be used to reshape the neck. These include the options of liposuction, submentoplasty, chin implants and the direct necklift. Often putting together two of these procedures is done to optimize their effects. But none of these procedures should be confused with creating the same effect as a facelift in the aging neck and it is important to realize their limitations.

Liposuction of fat can be very effective in reducing neck fullness. But that is dependent on how much fat actually exists in the neck and, most importantly, the quantity of neck skin and its tone. Loose neck skin will not respond to liposuction the way many older patients would like. The neck may indeed get less full but the skin may retract poorly and leave more visible folds and irregularities. Even with liposuction technology such as Smartlipo, which aids the fat removal process by a heating effect, significant loose skin will not be dramatically tightened. While I have seen some surprisingly good results with its use in the older neck, it is not a replacement for an excisional or lifting procedure for loose skin. When using it patients have to be willing to accept these skin issues or be ready to have a facelift later if they want further improvement.

The submentoplasty procedure is another method of neck fat removal but does not rely on liposuction at all. It is the removal of fat from underneath the platysma muscle and is often done as part of a facelift. Through an incision under the chin, the fat is seen through the separated platysma muscles in the midline. When done in a facelift, I use a ‘kelly clamp’ technique to remove the upper portion of the fat pad and then close the muscles over it. For those fuller necks with a lot of subplatysmal fat, a submentoplasty can make a dramatic change in the neck angle in side view. But like liposuction, its success as an isolated procedure depends on how well the skin retracts, which is why it works best in younger patients. In older necks, such fat removal can create skin dimpling and a central neck indentation.

Skin removal in the neck can be done without a traditional facelift. It is not commonly done as one might expect due to the scars that are created. But for the right patient who is fully educated, the scar may be a worthwhile trade-off. The direct necklift uses a vertical removal of skin from the chin down to the lowest horizontal neck skin crease. But skin alone is not just removed. All of the fat underneath this skin and even subplatysmal fat can be removed. The platysma muscle is then sewn together in the most dramatic form of neck muscle tightening due to the visual exposure that the surgeon has. The direct necklift produces the most significant neck angle change, even compared to the traditional facelift. Other types of neck excision or lifts exist, such as a submental tuck or a necklift that uses incisions behind the ears only, but their effects are very limited.


A chin implant is often a surprising suggestion to many older patients when discussing their neck concerns. It is a complementary procedure that increases the prominence of the jaw and by so doing lengthens the upper neck. While not enough alone to change a neck as much as a patient would like, it is a common component of many facelift procedures. It can be used with any of the non-facelift neck procedures and is conveniently done through a submental incision.

While there are a variety of surgical options for neck rejuvenation in older patients, their effects are limited. What they can do should not be confused with that of a facelift (with the exception of a direct necklift) and should be chosen only because one is more interested in less cost and recovery. For the neck with a lot of sag and droop, none of these more limited procedures may be a good option.


Dr. Barry Eppley

Indianapolis, Indiana

Options in Neck Reshaping and Contouring

Friday, October 21st, 2011

The shape of the neck is an important aesthetic structure of the face. When it is well defined with a sharp angle definition (between 90 to 120 degrees in profile), it makes the chin and jawline more prominent and flattering. When the neck angle is obtuse or completely open (straight), the jawline becomes obscured and less aesthetically pleasing. The neck can be seen to have a major influence on how the entire lower third of the face looks. As one begins to age, the neck tissues become loose and begin to sag.For some, even at a young age, they have a naturally full with an obtuse angle due to a thicker fat layer and a lower positioned hyoid bone.

While genetics, gravity and time work against a shapely neck with a good angle, there are a number of plastic surgery procedures to improve the aesthetic appearance of the neck. First, however, a few comments on non-surgical reshaping methods. While creams and exercises are touted to improve the shape of the neck, none have been proven effective for making noticeable changes. Some modest changes can be made in the appearance of jowls and neck skin sagging in those who have good skin elasticity withvarious transcutaneous energy therapies. (e.g., BBL or Skin Tyte) These are not to be confused with surgical results but there can be visible improvement. Injectable Botox can also be used to treat prominent vertical platysmal neck bands. These are best viewed as treatments neck for those that don’t have enough of a problem to justify surgery or for those who do but prefer to try a non-surgical approach first.

Full thicker necks with good skin can be treated solely by liposuction. Removing fat allows the skin to shrink and tighten up to reveal the shape of the underlying platysma muscle. While traditional liposuction is effective,the additional use of a laser-assisted technique can help improve the results. Smartlipo, which uses a fiberoptic laser probe, creates heat which not only helps melt fat but can create a skin tightening effect as well. While neck Smartlipo is ideal for younger patients due to their better skin quality, I have seen a few older patients with impressive neck changes as well.

The next level beyond neck liposuction is a submentoplasty. This is a neck tightening operation that not only removes fat by liposuction but tightens the platysma muscle as well. It is performed through a submental incision in which some small amount of loose upper neck skin can also be removed. Also known as a submental tuckup, it can be effective for the very beginnings of neck sagging in younger patients with good skin. It is also historically used after a facelift when some submental skin sagging develops (rebound relaxation) in the first year after surgery.

Facelifts are the primary procedure that can create the most effective change for the aging neck. Facelifts, also called necklifts, can be thought of as being two fundamental types either a limited and full type. Both use incisions around the ear but the length of the incisions and what effects they create in the neck and jowls is different. A limited facelift, which goes by a lot of marketing names (Lifestyle Lift, Quicklift etc), has as its main effect the smoothing out of sagging jowls with a more limited effect in lifting neck skin. It is best used in patients whose primary complaints are about their droopy jowls and not their necks. Full facelifts are used when the neck problem is more significant and its improvement is the main objective of the surgery. It is the most powerful changer of both the neck and jowls and usually also incorporates liposuction of neck fat and tightening of the platysma neck muscles. Chin augmentation with a facelift can also be helpful in giving a more defined jawline.

One other approach to the sagging neck is that of the direct necklift. Unlike facelifts in which the incisions and the direction of skin lifting is based around the ears, the direct necklift removes loose neck skin by excising it down the center of the neck…directly if you will. This is a simpler approach to a necklift and is a very powerful reshaping method of the neck but it does so with the trade-off of a midline neck scar. This can be a preferred procedure for older men (greater than age 65) who prefer the least recovery and have large hanging neck wattles. Male beard skin heals remarkably well and I have not found the neck scar to be a visible concern after it heals.

The last area of neck reshaping, which has nothing to do with age, is the prominent Adam’s apple or thyroid cartilage. For those that have too strong of a neck bulge caused by the strength of the paired cartilages of the Adam’a apple, this can be reduced by shaving the prominence down. This is done through a small horizontal neck incision directly over the prominence. It is a virtually painless procedure with no recovery and a result that is immediate. Most patients obtain results where the size of the bulge is dramatically reduced and a few will end up with a completely smooth neckline.

Dr. Barry Eppley

Indianapolis, Indiana

Submentoplasty For Witch’s Chin Deformity in Denture Patients

Wednesday, July 13th, 2011

The chin is a portion of the jaw bone that not only juts outward but is also enveloped by soft tissue attachments. The mentalis muscle is one of the dominant muscles of the chin. It is a paired central muscle which has a significant effect on the lower lip. It has fibers which attach below the mandibular vestibule, known as the incisive fossa of the mandible, and then descends vertically downward to insert into the skin of the skin. It is a muscle of facial expression as it raises and pushes up the lower lip and causes wrinkling of the chin, making a pout.

While this facial expression function seems rather trivial, if the mentalis muscle loses it bony attachments one will have something to pout about. This is an unfortunate occurrence that occur from intraoral chin procedures and, most commonly, after a chin implant has been removed or from multiple chin surgeries. When the mentalis muscle loses its superior bony anchoring point, the entire chin soft tissue pad can droop. This has a classic name which well defines its appearance, known as a ‘witch’s chin’, with the chin pad falling off of the end of the bone.

The correction of the witch’s chin deformity has been well described with the mainstay treatment approach of mentalis muscle resuspension. Multiple methods of how to fix the muscle to the chin bone have been described. While it is a relatively straightforward procedure from a technical standpoint, getting a stable result with tight tissue adaptation across the convex chin is not always easy or successful.

While the common origin of a witch’s chin is chin implant surgery, many older patients who have never had chin surgery have it. It is actually exceedingly common and everyone has seen someone with it. It is the result of a natural process that largely affects older individuals….tooth loss.


With loss of the teeth of the lower jaw and the wearing of dentures, the top portion of the jaw bone known as the alveolus resorbs away. This is the result of no teeth as well as the pressure of wearing dentures on top of this bone. In the front part of the mandible, when the alveolar loss becomes severe, the bone resorbs down to the attachments of the mentalis muscle. If severe enough the bone loss resorbs down to the level of the mentalis muscle’s upper attachments…and the chin pad falls downward.

This is a well recognized facial look in many older individuals. This edentulous witch’s chin is not correctable by mentalis muscle reattachment since there is no bone on which to anchor it. Rather it has to be treated from underneath through a submentoplasty approach. The excessive hanging tissues have to be excised, tightened, and secured to the bottom edge of the chin bone. This will get rid of the inverted v-deformity seen in profile under the chin.

The edentulous witch’s chin deformity is the result of a natural aging process rather than one caused by surgery and cosmetic manipulation. It can be successfully treated by removing the loose hanging tissues rather than muscle resuspension.

Dr. Barry Eppley

Indianapolis, Indiana

Neck Rejuvenation with Liposuction vs. Submentoplasty

Monday, July 4th, 2011

A lower facelift, technically a neck-jowl lift, is the standard approach for improving an aging neck or an obtuse cervicomental angle. This has been historically true but as the average age of people seeking neck and jawline improvement continues to lower, some altered approaches are needed. Younger people do not want a ‘facelift’or an extensive procedure but seek something less invasive with a quicker recovery. In the properly selected patient, liposuction of the neck or a submentoplasty may just be what they are looking for.

These minimally invasive neck procedures are usually best done for patients in their 30s and 40s, although I occasionally have treated older patients as well with them. The key is the quality and amount of neck skin and how much fat there is. This can be determined by feeling the neck, pinching the neck skin and having the patient swallow. Full necks or those with an obtuse cervicomental angle usually have fat both above and below the platysma muscle. Knowing whether the removal of fat is needed below the muscle is important in determining whether liposuction alone or a submentoplasty is needed.

What is the difference between liposuction and submentoplasty? Liposuction is well recognized and exclusively removes fat through a small skin nick under the chin. It can effectively remove supraplatysmal fat in the central neck, jowls and out close to the anterior border of the sternocleidomastoid muscle. A submentoplasty incorporates liposuction but goes further. Through a larger submental ckin crease incision, a skin flap is raised with facelift scissors after liposuction has been initially done. The platysma muscle is then opened down the middle with a ‘cautery clamp’ technique. Subplatysmal fat is then removed and the muscle edges put together with sutures. (others have described their method of submentoplasty, this one is the way I prefer to do it)

Like liposuction, a submentoplasty ultimately shows its degree of improvement by the contraction of the overlying skin. This is why the thickness and elasticity of the neck skin is so critical in determing how successful these procedures will be in improving neck and jawline definition without a lot of irregularities. This is also why the use of neck compression through circumferential garments (facelift bra) is important during the first week after surgery.

With any neck reshaping procedure, it is important to look at chin projection as well. Many full neck with an obtuse cervicomental angle have a weaker or poorly projecting chin. The use of a chin implant can make a dramatic improvement, in some cases as significant as the improvement in the neck angle. This ‘ying and yang’ approach, bringing the chin forward as the neck comes back, can have a very rejuvenating look to the neck.

While neck liposuction or a submentoplasty do not replace the need for a lower facelift, they can produce significant change in the right patient. Age (less than 50 years old) is one of the best indicators of whom these procedures work best in but not exclusively so.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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