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Defining the Facial Extent of the Platysma Muscle a Review of 71 Consecutive Face-Lifts

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Defining the Facial Extent of the Platysma Muscle a Review of 71 Consecutive Face-Lifts ORIGINAL ARTICLE Defining the Facial Extent of the Platysma Muscle A Review of 71 Consecutive Face-lifts Anil R. Shah, MD; David Rosenberg, MD Objective: To delineate the superior (facial) extent of Results: On average, the platysma extended 3.98 cm the platysma muscle. along the malar mandibular line, superiorly from the in- ferior border of the mandible. The platysma was located 3.09 cm inferiorly from the malar eminence along the ma- Methods: A total of 142 facial halves were examined from lar mandibular line. On average, the platysma muscle oc- 71 consecutive deep-plane rhytidectomies performed over cupied 56% of the malar mandibular line. a period of 3 months. The platysma muscle was identi- fied and isolated during the procedure. The superior ex- Conclusion: The platysma muscle may have a more sig- tent of the platysma was measured along the line cre- nificant facial extension than previously described. ated by the angle of the mandible to the malar eminence, also known as the malar mandibular line. Arch Facial Plast Surg. 2009;11(6):405-408 ESPITE THE MYRIAD OF the extent of the platysma muscle can be face-lift techniques avail- clearly seen, based on the directional as- able, few surgeons who pects of the muscle fibers and the often perform face-lifts would thick nature of the facial platysma. Dur- question the role that the ing surgery, attenuation of the facial pla- platysma muscle plays in rejuvenation of tysma can be seen clearly at the midface D 1 the aging neck. However, the extension along its superior extent. of the platysma into the face has not been The platysma muscle is a thin sheet- well described. Many anatomy textbooks like muscle that originates on the fascia of depict the platysma muscle with its supe- the deltoid and pectoral regions and runs rior border limited by the inferior edge of superiorly and medially, inserting on the the mandible (Figure 1).2 However, we mandible, the skin of the cheek, the com- believe that the platysma muscle has a sig- missure of the mouth, and the orbicu- nificant facial extension onto the face laris oris muscle.3 The only bony inser- (Figure 2). One of us (D.R.) has devel- tion of the muscle lies on the anterior third oped a technique—a variant of deep- of the mandible. When the platysma plane rhytidectomy—in which the pla- muscle tenses, it lifts the neck out (accen- tysma muscle is isolated within the face tuating platysmal bands) and lowers the and neck. Based on more than 7 years of eyelids and midface (accentuating the ma- experience with this technique and more lar and nasolabial folds) and the man- than 1000 patients treated, the platysma dible (making the neck shorter and wider), muscle has been shown to constitute a making it the major muscle responsible for critical component in the facial aging pro- the emotive response of surprise. Clini- cess. To support this theory, we per- cally, the actions created by the platysma formed a prospective anatomic study on clearly demonstrate a significant facial 71 consecutive patients undergoing component. Author Affiliations: Divisions rhytidectomy. Many of the mentioned findings asso- of Facial Plastic Surgery, During deep-plane rhytidectomy, a ciated with platysma muscle activity are Departments of Otolaryngology, 4 University of Chicago, Chicago, unique anatomic perspective exists when seen with natural aging. With advancing Illinois (Dr Shah), and the dissection takes place along the un- age, the platysma tends to become thin- 3 Manhattan Eye, Ear, & Throat dersurface of the platysma muscle ner and less defined. In addition, nor- Hospital, New York, New York (Figure 3 and Figure 4). When the mas- mal aging will cause the platysma muscle (Dr Rosenberg). seteric fibers are released and separated, to sag and weaken, which creates un- (REPRINTED) ARCH FACIAL PLAST SURG/ VOL 11 (NO. 6), NOV/DEC 2009 WWW.ARCHFACIAL.COM 405 ©2009 American Medical Association. All rights reserved. Figure 1. Artist’s depiction of the platysma muscle demonstrates the Figure 2. Artist’s depiction of the clinical superior extent of the platysma classical concept of the superior extent of the muscle limited to the inferior muscle attenuated near the midface. border of the mandible. sightly platysmal bands or ptosis of the muscle and un- derlying tissues. The platysma is the most superficial muscular layer of the face and is innervated by the cervical branch of the facial nerve. Embryologically, the platysma muscle is derived from the more superficially lying platysma fas- cia rather than the deeper-lying sphincter colli, in which the muscles of the face arise.5 Beneath the platysma muscle within the face lies an embryologic glide plane that sepa- rates the platysma muscle, derived from the second bran- chial arch, from the deeper-lying masseter, a derivative of the first branchial arch. The goal of this study was to measure the superior ex- tent of the facial platysma muscle. The implications and applications of our findings are briefly discussed. METHODS Based on more than 7 years of experience and more than 1000 patients in whom this technique has been used, we conducted a prospective study in which the anatomy of the platysma was ana- lyzed in 71 consecutive deep-plane face-lifts performed from Oc- tober 1 through December 31, 2007. Patients included in this study underwent primary, revision, and multiple revision face-lifts. Figure 3. Artist’s depiction of the platysma muscle with a significant extent All procedures in this study were performed by one of us into the midface when the skin of the face is lifted. (D.R.). The technique used is a unique variant of a deep-plane rhytidectomy, in which the platysma muscle is isolated and iden- tified within the face and neck. To isolate the facial compo- the line created by the true zygomatic insertion point to the nent of the platysma, a No. 10 blade scalpel is used to dissect angle of the mandible. Dissection deep to the platysma muscle the superficial musculoaponeurotic system (SMAS) laterally from occurs approximately 1 cm posterior to the nasolabial fold along (REPRINTED) ARCH FACIAL PLAST SURG/ VOL 11 (NO. 6), NOV/DEC 2009 WWW.ARCHFACIAL.COM 406 ©2009 American Medical Association. All rights reserved. Malar eminence Figure 4. Intraoperative photograph shows the platysma in relation to the B mandible and zygoma. Contrary to many anatomic descriptions, the platysma muscle will often have a thick muscular component in the face as shown. A the face and 2 cm below the mandible. Oblique fibers of the Mandibular angle platysma muscle are clearly seen on the undersurface of the dis- section, distinguishing it from the underlying muscles in the face. The direction of the fibers of the platysma muscle distin- guish it from other underlying muscles along the face. For our study, the platysma muscle was measured along the line created by the angle of the mandible to the malar eminence, also known as the mandibular malar line (MML), by the same surgeon (D.R.). These landmarks were chosen in part because they were easily palpated and replicable from one patient to another. In addition, the fibers of the pla- Figure 5. Artist’s depiction shows the measurements from the mandibular tysma muscle tend to parallel this line. The superior extent angle to the malar eminence, a line termed the malar mandibular line. Line A of the platysma muscle was measured from the inferior bor- refers to the line created by the angle of the mandible to the superior extent der of the angle of the mandible along the MML to the of the platysma, whereas line B refers to the superior extent of the platysma attenuation point of the platysma (Figure 5, line A). An to the malar eminence. additional measure was taken from the malar eminence to the superior border of the platysma along the MML, termed line B (Figure 5). The distance of the MML was calculated in In the 17 patients undergoing revision face-lifts, line every patient, because of the normal variance associated with A averaged 3.27 cm, whereas line B averaged 3.04 cm, face size. meaning that the platysma occupied 52% of the face. Fifty- four patients underwent primary rhytidectomy, and lines RESULTS A and B in these patients averaged 4.32 and 3.11 cm, re- spectively, with the platysma occupying 58% of the face. The facial platysma was found to be lower along the MML Overall, 71 consecutive patients underwent deep-plane in patients undergoing revision compared with primary rhytidectomies in which the platysma muscle was mea- rhytidectomy. sured. Sixty-four patients were women and 7 were men. Seventeen patients had undergone previous rhytidecto- mies, whereas 54 underwent primary face-lifts. COMMENT For all patients, the average distance of line A, the su- perior extent of the platysma muscle along the MML from This is, to our knowledge, the first study to formally de- the angle of the mandible, was found to be 3.98 cm. The termine the facial extent of the platysma. The tradi- average distance from the malar eminence to the supe- tional view of the platysma (see Figure 1) depicts a muscle rior border of the platysma muscle along the MML, line that is mostly cervical in nature. However, our study dem- B, was 3.09 cm. The platysma muscle occupied 56% of onstrates that the platysma muscle has a significant ex- the distance of the MML. tension onto the face (see Figure 2). In the 7 male patients in the study, line A averaged There are several reasons why we believe that the fa- 3.65 cm, whereas line B averaged 3.15 cm, occupying 54% cial component of the platysma has been underappreci- of the face.
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