Research

JAMA Facial Plastic Surgery | Original Investigation

Analysis of Cervical Angle in the Submental Muscular

Medialization and Suspension Procedure
Phillip R. Langsdon, MD; Shilpa Renukuntla, MD; Amani A. Obeid, MD; Aaron M. Smith, MD; Nicholas S. Karter, MD

IMPORTANCE The submental muscular medialization and suspension (SMMS) procedure is an

option for addressing an obtuse cervical angle in select patients vs the use of traditional
rhytidectomy techniques.

OBJECTIVE To compare the change in position of the cervical point between groups
undergoing SMMS vs the traditional rhytidectomy technique.

DESIGN, SETTING, AND PARTICIPANTS A retrospective review was performed of 141 patients
undergoing rhytidectomy in an accredited private surgery center between January 1, 2013,
and December 31, 2014, comparing cervical point depth between patients undergoing SMMS
vs those undergoing traditional rhytidectomy with platysma plication. Statistical analysis was
performed from November 11, 2017, to January 5, 2018.

INTERVENTIONS Patients underwent either SMMS or traditional rhytidectomy with platysma

plication.

MAIN OUTCOMES AND MEASURES The primary end point was change in the cervical point
distance between preoperative and postoperative standardized profile photos.

RESULTS A total of 141 patients were included in the analysis. A cohort of 46 patients (43
women and 3 men; mean age, 63.5 years [range, 49.0-79.0 years]) underwent neck
contouring with the SMMS technique and a cohort of 95 patients (90 women and 5 men;
mean age, 61.0 years [range, 48.0-73.0 years]) underwent traditional rhytidectomy with
platysmaplasty. The cervical point distance of the SMMS cohort had a mean (SD)
postoperative increase of 2.0 (1.05) cm (95% CI, 1.73-2.28; P < .001) compared with 0.78
(0.82) cm in the traditional rhytidectomy cohort (95% CI, 0.54-1.02; P < .001).

CONCLUSIONS AND RELEVANCE The results of this study suggest that submental muscular
medialization and suspension appears to be an effective option to address the obtuse neck in
select patients.

LEVEL OF EVIDENCE 3.

Author Affiliations: Division of Facial

Plastic Surgery, Department of
Otolaryngology–Head and Neck
Surgery, University of Tennessee,
Germantown (Langsdon); Private
Practice, Flemington, New Jersey
(Renukuntla); Division of Facial Plastic
Surgery, Department of
Otolaryngology–Head and Neck
Surgery, King Saud University, Riyadh,
Saudi Arabia (Obeid); Department of
Otolaryngology–Head and Neck
Surgery, University of Tennessee,
Memphis (Smith); The Langsdon
Clinic, Germantown, Tennessee
(Karter).
Corresponding Author: Nicholas S.
Karter, MD, The Langsdon Clinic,
JAMA Facial Plast Surg. doi:10.1001/jamafacial.2018.1097 7499 Poplar Pk, Germantown, TN
Published online October 4, 2018. 38138 (nskarter@gmail.com).

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 Research Original Investigation
I
n the last several decades, rhytidectomy techniques have
undergone continuous refinements. Despite this evolu-
tion, inferiorly displaced hyoid bones, large submental fat
pads, and diastasis of the midline neck musculature often limit
optimal improvement of the cervical region of the face. It has
been the practice of one of us (P.R.L.) for the last decade to ad-
dress some conditions of obtuse cervical angle with the sub-
mental muscular medialization and suspension (SMMS) tech-
nique.
Submental muscular medialization and suspension uses
the removal of midline subplatysmal fat to expose the medial
borders of the anterior digastric muscles. The borders of pla-
tysma and anterior digastric musculature are then medial-
ized and suspended posteriorly and superiorly to the mylo-
hyoid fascia using suture plication. In appropriate candidates,
the resultant repositioning of the cervical point yields an in-
creased acuity of the cervicomental angle.
The SMMS technique has been detailed in previous pub-
lications by Langsdon and Moak.1 However, at the present time,
to our knowledge, there are no studies comparing results of
SMMS vs traditional rhytidectomy with platysma plication. In
addition, many previous studies evaluating neck contouring
techniques have used subjective assessment methods, includ-
ing patient satisfaction and independent ratings of youth, at-
tractiveness, success, and health.2 To increase objectivity in
evaluating postoperative results, this study assessed cervical
point position as a surrogate for hyomental distance and the
cervicomental angle. Cervicomental angle and hyomental dis-
tance have both been used in prior studies to objectively ana-
lyze outcomes in rhytidectomy.3
Methods
A retrospective observational analysis was undertaken of all
consecutive patients undergoing rhytidectomy between Janu-
ary 1, 2013, and December 31, 2014. Selection criteria in-
cluded patients receiving rhytidectomy with cheek and neck
lift, with or without concomitant procedures. Patients under-
going isolated cervicofacial liposuction without platysma-
plasty, neck contouring without submental incision, or ad-
junct chin implantation were excluded. Those with less than
1 year of follow-up were also excluded from the analysis. Pa-
tients meeting the inclusion criteria were divided into the fol-
lowing 2 cohorts: those undergoing rhytidectomy with SMMS
and those undergoing rhytidectomy with traditional platys-
maplasty. Group characteristics and the surgical outcomes of
the 2 cohorts were compared. Institutional review board ap-
proval was obtained from the University of Tennessee Health
Science Center and a waiver of patient consent was granted by
this board because the research involved no more than mini-
mal risk to the patient and could not be predictably carried out
without such a waiver.
Age, sex, follow-up period, complications and postopera-
tive change in cervical point depth were analyzed. All cases
were performed by one of us (P.R.L.) at a private, state-
licensed, Medicare-certified surgery center. Standardized,
5-view rhytidectomy photographs were recorded before sur-
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Cervical Angle in the Submental Muscular Medialization and Suspension Procedure
Key Points
Question Does the submental muscular medialization and
suspension procedure produce greater improvement of the
cervical angle in select patients vs traditional rhytidectomy
techniques?
Findings In this cohort study of 141 patients undergoing
rhytidectomy, analysis of the change in cervical point position
after submental muscular medialization and suspension revealed a
statistically significant 2-cm increase in point depth.
Meaning In select patients with obtuse cervicofacial angle and
large submental fat pads, the submental muscular medialization
and suspension technique appears to be an effective option to
improve cervical point depth and cervicofacial angle.
Figure 1. Technique for Measuring Change in Cervical Point Distance
A Before surgery B After surgery
7.1 cm
0.3 cm
A, Before surgery. B, After surgery. A vertical line is drawn from the subnasale
through the pogonion. A horizontal limb is drawn 90° tangential to the vertical,
through the deepest cervical point. The difference in horizontal limb length
represents the change in cervical point distance.
gery and throughout the follow-up period. Cervical point depth
was used as a marker for surgical outcome. The cervical point
was measured before and 1 year after surgery for all patients.
Lateral view photographs taken in horizontal Frankfurt plane
were used for assessment of the cervical point. The cervical
point depth was determined by creating a 90° right angle be-
tween a horizontal line drawn through the deepest cervical
point and a vertical line passing through the fixed bony land-
marks of the subnasale and pogonion (Figure 1). The postop-
erative change in horizontal limb distance from the cervical
point was measured and compared between the 2 cohorts. All
photographs were standardized in terms of focal length and
distance to the camera. Photographs were assessed using Mir-
ror software (Canfield Scientific).
Description of Surgical Techniques
In the traditional rhytidectomy with platysma plication per-
formed by one of us (P.R.L.), the submental area is addressed
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 Cervical Angle in the Submental Muscular Medialization and Suspension Procedure
Figure 2. Submental Muscular Medialization and Suspension (SMMS) Technique
A Exposure of preplatysmal fat B Excision of preplatysmal fat
E Suture medialization of the digastric F Suture medialization of the
muscles platysma
A, Exposure of preplatysmal fat. B, Excision of preplatysmal fat. C, Excision of
subplatysmal fat with exposure of the digastric muscles and mylohyoid fascia.
D, Suture medialization of the digastric muscles with suspension to the
mylohyoid fascia. E, Suture medialization of the digastric muscles with
through a 2.5-cm incision. Subcutaneous elevation of the skin
is completed widely and inferiorly, just beyond the thyroid
notch, with sharp and blunt dissection. A 4-mm liposuction
cannula is used for superficial liposuction of preplatysmal fat.
If significant submental fat pad is present, limited lipectomy
in the midline can be completed. A strip of the dehisced mid-
line platysmal fascia is then removed and platysmal bands, if
present, are divided as low as the thyroid cartilage. Inter-
rupted, buried mattress sutures are next used to plicate the me-
dial borders of the platysma, similar to corset platysmaplasty.4
The skin is closed with a running, locking suture.
The SMMS technique (Figure 2) differs from the above tech-
nique. In the SMMS technique, after the exposure of the me-
dial borders of the platysma muscle, a layer of subplatysmal
fat is removed and the mylohyoid fascia is exposed at the deep
extent of the dissection and the anterior digastric muscula-
ture is exposed at the lateral extent. A thin layer of fat supe-
rior to the digastric muscles, when present, can also be re-
moved with judicious liposuction. The mylohyoid muscle is
now exposed between the medial borders of the anterior bel-
lies of the digastric muscles. The resultant void after subpla-
tysmal fat excision is closed by plicating and suspending the
medial borders of the digastric muscles with interrupted, bur-
ied sutures. A total of 2 to 3 sutures are needed to complete
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Original Investigation Research
C Excision of subplatysmal fat D Suture medialization of the digastric
muscles
G Before SMMS H After SMMS
suspension to the mylohyoid fascia. F, Suture medialization of the platysma. G,
Before SMMS; H, After SMMS. The images were created by and reproduced
with the permission of Phillip R. Langsdon, MD.
the plication from just above the hyoid to the submental
crease.1,5 Plication of the digastric musculature results in pos-
terior and superior displacement of the cervical point. Platys-
mal plication is then completed, with deep portions of each
suture suspending to the deeper digastric muscles. Addi-
tional lateral cutaneous undermining is used to correct any cu-
taneous bunching.
Statistical Analysis
Statistical analysis was performed from November 11, 2017, to
January 5, 2018. All results were analyzed using IBM SPSS Sta-
tistics, version, 24 (IBM Corp). Standard t test was used to com-
pare the change in cervical point position of patients who un-
derwent SMMS with those undergoing traditional facelift with
platysmaplasty. All P values were from 2-sided tests and re-
sults were deemed statistically significant at P < .05.
Results
A total of 141 patients met inclusion criteria and were in-
cluded in the analysis. Forty-six patients (32.6%) underwent
neck contouring with the SMMS technique (43 women and 3
men; mean age, 63.5 years [range, 49.0-79.0 years]) and 95 pa-
(Reprinted) JAMA Facial Plastic Surgery Published online October 4, 2018 E3
 Research Original Investigation
Figure 3. Patient Before and 12 Months After Rhytidectomy With
Submental Muscular Medialization and Suspension, Upper Lid
Blepharoplasty, and Lower Lid Blepharoplasty
A Before surgery B After surgery
A, Before surgery. B, After surgery. Note the change in cervical point and acuity
of the cervicomental angle.
tients underwent traditional rhytidectomy (90 women and 5
men; mean age, 61.0 years [range, 48.0-73.0 years]). A deci-
sion to perform SMMS was made by one of us (P.R.L.) for pa-
tients considered to have significant anatomical variations that
were unlikely to be corrected with traditional rhytidectomy.
Palpation of substantial midline deep subplatysmal fat in the
presence of an obtuse cervical angle was used to determine the
possibility of angle improvement. All patients who met inclu-
sion criteria were included in the final analysis, with no loss
to follow-up.
The cervical point distance measured from the pogonion
showed a mean (SD) increase postoperatively of 2.0 (1.05) cm
(95% CI, 1.73-2.28; P < .001) compared with 0.78 (0.82) cm in
the non-SMMS group (95% CI, 0.54-1.02; P < .001).
Two patients in the SMMS group (4.3%) required early
needle aspiration for a small submental serosanguinous accu-
mulation, as did 5 patients (5.3%) in the non-SMMS group. One
patient in each group required opening of the submental in-
cision for evacuation. There were no cases of facial paralysis
in either group. Two patients in the SMMS group (4.3%) and 4
patients in the non-SMMS group (4.2%) required the applica-
tion of nitroglycerin, 2%, ointment (Nitro-Bid; Fougera Co) 3
times a day for decreased perfusion of the posterior skin flap.
No patient had skin loss or permanent scarring requiring re-
operation. No patient required surgery for scar revision.
Discussion
Despite years of evolution in rhytidectomy techniques, a sub-
group of patients characterized by an inferiorly positioned hy-
oid, large submental fat pad, and an obtuse cervicofacial angle
E4 JAMA Facial Plastic Surgery Published online October 4, 2018 (Reprinted)
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Cervical Angle in the Submental Muscular Medialization and Suspension Procedure
often have less than desirable improvement in the cervical
angle after traditional rhytidectomy. It has been the practice
of one of us (P.R.L.) to use the SMMS technique to achieve im-
proved results in properly selected patients. Patients were se-
lected for this technique either by presurgical palpation of sub-
platysmal fat between the base of the tongue and hyoid or on
discovery during the surgical procedure. Despite anecdotal suc-
cess with this technique, to our knowledge, no study cur-
rently exists that objectively compares the results of SMMS
technique with those of traditional rhytidectomy tech-
niques.
The results of this investigation support the notion that ap-
plication of the SMMS technique in select patients can aid in
achieving an improved cervicomental angle beyond that
achievable with traditional rhytidectomy techniques. Pa-
tients undergoing the SMMS technique during the time pe-
riod defined in the study achieved a mean (SD) posterior dis-
placement of the cervical point of 2.0 (1.05) cm, compared with
a mean (SD) posterior displacement of 0.78 (0.82) cm in those
undergoing standard rhytidectomy technique using pla-
tysma plication. The posterior displacement of the cervical
point increases the acuity of the cervicomental angle, a criti-
cal feature of the youthful neckline.
Removal of the subplatysmal, submental fat pad and me-
dialization of the anterior digastric muscles distinguishes this
technique from traditional plastysma plication techniques. Ac-
cordingly, the void created and filled by plicating the medial
borders of the platysma and digastric muscles likely accounts
for the increases in the cervical point distance identified in the
study. This increase in distance can be particularly robust in
patients with a large subplatysmal medial fat collection, as has
been the experience of one of us (P.R.L.) (Figure 3).
The technique has its limitations. Although the subpla-
tysmal fat can be addressed in the midline, it is not techni-
cally practical to attempt eradication of subplatysmal fat very
far lateral to the anterior digastric muscles. In addition, de-
spite posterior and superior anchoring of the midline muscu-
lar tissue, hyoid position still places a limiting factor on the de-
gree of improvement that can be obtained. Thick anterior
digastric muscles may also limit improvement. However, these
muscles may be shaved with sharp and electrocautery dissec-
tion to reduce muscle bulk. Despite these limitations, the SMMS
technique still provides superior results for select patients com-
pared with traditional techniques, with no concomitant in-
crease in the risk or complication profile of the procedure.
Failure to medialize and suspend the deep musculature af-
ter removal of the fat between the deep surface of the platys-
mal muscle plane and the mylohyoid fascia may result in a deep
cervical concavity. Failure of the suspension-medialization su-
ture may also result in a concavity. It is the routine of one of
us (P.R.L.) to use either a nonresorbable suture such as a large-
diameter Ethibond (Ethicon) or a long-lasting absorbable su-
ture such as 2-0 or larger polydioxanone (Ethicon). One of us
(P.R.L.) abandoned the use of quickly absorbable suture such
as Vicryl (Ethicon) because of the development of a midline
diastasis in the year before this study.
Another factor limiting maximal outcome is the patient
with advanced tissue elasticity loss, such as those with ad-
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 Cervical Angle in the Submental Muscular Medialization and Suspension Procedure Original Investigation Research

vanced age and severe musculocutaneous ptosis. In any pa-
tient with advanced tissue ptosis who is undergoing rhytidec-
tomy, it is our normal practice to remind patients of the possible
need for a rhytidectomy tuck up procedure as early as 1 year
after surgery because of the degradation of youthful tissue elas-
ticity. This is especially important in candidates for the SMMS
procedure because lateral cervical resagging will enhance any
slight submental concavity. Therefore, when faced with ad-
vanced musculocutaneous ptosis, advanced age, and an ob-
tuse cervical angle resulting from ptosis and subplatysmal fat,
performing secure deep plane cheek elevation, careful sub-
mental SMMS sculpting, and a planned 1-year repeated supe-
rior advancement of cheek flaps may be necessary to achieve
optimal results.
Limitations
This study is limited in the selection bias of patients under-
going the SMMS technique. As not all patients require the
implementation of the SMMS technique, it is impossible to truly
randomize patients to treatment groups. The experience and
expertise of the surgeon in evaluating a patient’s anatomy with
consideration of his or her desired results is paramount to de-
termining the intervention most suitable. This limitation was
mitigated to the best of our ability with use of a large sample
size and evaluation of all patients during the study to provide
for the broadest range of presurgical neck condition. Intui-
tively, one would expect that surgical results would improve
as the surgeon’s familiarity with the technique increased. Our
results may be on the higher end of the spectrum of expected
outcomes using this particular technique.
Conclusions
The SMMS technique has been used to help address subopti-
mal outcomes from traditional rhytidectomy in patients with
an obtuse cervical mental angle. The technique, using the re-
moval of the midline subplatysmal fat with medialization and
superior suspension of the midline neck musculature, has pro-
vided improved anecdotal results in the past. This study ob-
jectively verifies a significant increase in the distance of the
cervical point achieved using the SMMS technique compared
with rhytidectomy with platysma plication alone. The SMMS
technique should be considered an appropriate option to
achieve desirable results in properly selected patients with large
submental fat pads, a low-lying hyoid bone, and diastasis of
the deep, midline neck musculature and an obtuse cervical
angle.

ARTICLE INFORMATION
Accepted for Publication: July 3, 2018.
Published Online: October 4, 2018.
doi:10.1001/jamafacial.2018.1097
Author Contributions: Drs Renukuntla and Obeid
had full access to all the data in the study and take
responsibility for the integrity of the data and the
accuracy of the data analysis.
Concept and design: Langsdon, Renukuntla, Obeid,
Smith.
Acquisition, analysis, or interpretation of data: All
authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important
intellectual content: Langsdon, Karter.
Statistical analysis: Renukuntla, Obeid, Smith.
Administrative, technical, or material support:
Langsdon, Obeid, Smith, Karter.
Supervision: Langsdon, Karter.
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the patients
for granting permission to publish their
photographs.
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