Cosmetic
Anterior Cervicoplasty in the Male Patient
Gilbert P. Gradinger, M.D.
San Francisco, Calif.
Most men develop visible redundant tissue in the an-
terior neck with aging. Some seek surgical improvement.
If the patient does not wish to have a conventional face/
neck lift, anterior cervicoplasty is a good option. The
procedure accomplishes tightening in the horizontal di-
rection by excising a midline vertical ellipse of skin and
subcutaneous fat. The surgeon tightens and lengthens the
platysma muscles by suturing the anterior borders of the
muscle to each other and by performing one or more
Z-plasties in the muscle. A Z-plasty in the skin and sub-
cutaneous tissue predictably creates a mental/cervical
crease or angle with precise planning of the location of the
horizontal limb. It also provides added length to the ver-
tical skin closure. Every patient has thought that the im-
proved contour of his neck more than offset the presence
of a visible scar. In fact, no patient has indicated that his
scar has been noticed by others, nor has any patient re-
quested scar revision. (Plast. Reconstr. Surg. 106: 1146,
2000.)
The anterior cervicoplasty was performed on
37 men in the last 4 years, during which time
the technique has not changed. No complica-
tions have required reoperation, and no sero-
mas, hematomas, infections, hypertrophic
scars, or scar contractures have occurred. Hy-
popigmentation of the scar makes it more vis-
ible. Every patient received intravenous antibi-
otics approximately 30 minutes before the
surgery began, and all surgeries were per-
formed under intravenous sedation (midazo-
lam or fentanyl) and local (0.5% lidocaine with
1:500,000 adrenaline) anesthesia (usually 20 to
25 cc). Each patient was operated on in our
AAAASF-accredited office surgical suite as an
outpatient.
PATIENTS AND METHODS
Surgical Plan and Goals
A midline excision of skin and fat (subcuta-
neous and subplatysma) in the vertical direc-
From the University of California at San Francisco and Stanford University School of Medicine. Received for publication August 31, 1999;
revised October 25, 1999.
Presented at the Annual Meeting of the American Society for Aesthetic Plastic Surgery, in Los Angeles, California, May 2, 1998.
1146
tion overcomes horizontal laxity and fullness.
The neck in profile needs a horizontal upper
component and a vertical lower component.
This is accomplished by one or two Z-plasties in
the platysma muscle and a Z-plasty of the skin
and fat that places the horizontal limb of the Z
at the desired level of the mental/cervical an-
gle.
The upper Z-plasty in the platysma lies di-
rectly under the Z-plasty in the skin. The con-
cept of performing a Z-plasty in the platysma
muscle came about as a result of noting the
contracture of the sutured anterior borders of
the platysma muscle in women after a platys-
maplasty in association with rhytidectomy. It
seemed obvious that if the muscle alone could
form a contracting band without overlying skin
incisions, then surgery to interrupt the straight-
line closure of the muscle was necessary. The
reasoning then became a matter of creating a
Z-plasty at the desired level of the crease to
overcome that portion of the contracted mus-
cle.
The concept of a lower Z-plasty came about
as a result of the intraoperative observation
that repairing the anterior bands resulted in a
straight line of the lower portion of the
platysma. It is now routine to perform a Z-
plasty on the lower and upper portions of the
platysma muscle. The vertical length of the scar
extends from the mentum to as far inferiorly as
is necessary to excise the redundant tissue. It
may extend to the suprasternal notch.
Patient Selection
At the initial consultation, the options of a
face/neck lift or an anterior cervicoplasty are
described to the patient. Almost equal num-
bers of patients choose each procedures. Pa-
Vol. 106, No. 5 / ANTERIOR CERVICOPLASTY IN MEN
tients are advised that there will be a visible
scar. Photographic verification of the location
of the scar is demonstrated using representa-
tive preoperative and postoperative photo-
graphs of patients who have undergone each
procedure. Some patients have a blepharo-
plasty at the time of their rhytidectomy or cer-
vicoplasty.
Preoperative Photographs
Four standard photographs are taken. These
include a full face and neck frontal view, each
profile, and a submental vertex photograph to
demonstrate the preoperative condition and
the postoperative scar.
Preoperative Preparation
All patients are provided with a list of drugs
that can interfere with normal clotting and are
advised not to take any of them 14 days before
and after surgery. Complete blood count and
preoperative blood clotting tests are routinely
done.
SURGERY
All patients have an intravenous line in the
upper extremity, receive 1 g of cefazolin (An-
cef) 30 minutes before surgery, and are moni-
tored with an electrocardiogram, blood pres-
FIG. 1. (Left and center) Preoperative placement of measuring tape at the desired level of the submental cervical crease. (Right)
Midline vertical ellipse, which includes all of the redundant tissue. The horizontal line marks where the tape was placed previously.
This marking is completed with the patient in the sitting position.
1147
sure, and pulse oximetry. Incremental doses of
midazolam and fentanyl are used for sedation
and analgesia, respectively. Freshly mixed local
anesthesia (50 cc of 0.5% plain lidocaine and
0.1 cc of 1:100,000 adrenaline) is infiltrated
after marking the skin.
Markings
The patient is placed in the sitting position
on the operating table, and a tape measure is
placed across the neck from one mandibular
angle to the other, crossing the midline at the
level of the intended mental/cervical angle
(Fig. 1, left and center). This is an aesthetic
judgement. This angle may be at the level of
the hyoid bone or superior or inferior to it. It
is important to make this decision preopera-
tively because a proper final horizontal crease
is critical. A long horizontal line, correspond-
ing to the mental/cervical crease, is marked.
This line extends beyond the vertical ellipse to
be excised in a lateral direction.
With the patient still in the sitting position,
the midline vertical ellipse to be excised is
marked. This ellipse contains the full length
and breadth of the redundant soft tissue
(Fig. 1, right).
The patient is then positioned supine, and
local anesthesia is achieved with direct injec-
tion into the skin and subcutaneous tissue. In-
1148
cisions are delayed until blanching of the skin
is seen.
The skin incision is made with a scalpel. The
excision of skin and subcutaneous fat is per-
formed with an electrical surgical cutting/
cautery unit with a Colorado needle. The ex-
cised specimen is full-thickness skin and fat
(Fig. 2, above). Subplatysmal fat may be part of
the deformity and must also be excised (Fig. 2,
below).
Undermining the skin and subcutaneous fat
flap superficial to the platysma is done for 3 to
5 cm. Undermining the platysma is also impor-
tant so that the platysma Z-plasty and midline
PLASTIC AND RECONSTRUCTIVE SURGERY, October 2000
closure is completed without tension. Muscle
closure without adequate subcutaneous flap
undermining causes unnatural tension in the
skin and must be avoided.
Platysma Z-Plasty
The platysma Z-plasty at the level of the in-
tended crease is always performed whether the
fibers are decussated (Fig. 3, left) or not (Fig. 4,
above, left). The platysma Z-plasty gives firm
support to the suprahyoid structures (Fig. 4,
above, second from right). Equilateral triangular
flaps approximately 1 inch in length that form
an approximately 60-degree angle with the

FIG. 2. (Above, left) The Colorado needle used to excise the skin and fat (specimen is shown
with the fat up). (Above, right) The ellipse of skin and fat. (Below, left) Interplatysmal and
subplatysmal fat pad. (Below, right) Excised fat pad.
Vol. 106, No. 5 / ANTERIOR CERVICOPLASTY IN MEN 1149

FIG. 3. (Left) The upper part of platysma fibers are decussated. (Right) Upper and lower
platysma Z-plasty. The lower Z-plasty is performed to avoid a midline band and possible con-
tracture.

FIG. 4. (Above, left) Z-plasty marked in widely separated platysma muscles. (Above, second from
left) Interplatysmal fat is excised. (Above, second from right) Platysma Z-plasty is completed. (Above,
right) Three temporary sutures are placed, the middle of which is at the point where the
horizontal limb of the Z will be. The others are 1 inch above and 1 inch below the central suture.
The triangles are marked with 60-degree angles, and the limbs are 1 inch long. (Below, left) The
excised central ellipse and the interplatysmal fat. (Below, center) The completed closure. (Below,
right) Lateral neck profile at the conclusion of surgery.
1150 PLASTIC AND RECONSTRUCTIVE SURGERY, October 2000

FIG. 5. Compression face lift bandage worn full-time by patient after conclusion of surgery
for 1 week and then at night for 2 weeks.

midline are marked, incised, elevated, trans-
posed, and sutured with an absorbable suture
of choice (4-0 Vicryl or 4-0 monocryl). A sec-
ond platysma Z-plasty is usually done in the
lower portion of the muscle to avoid creating a
postoperative band or scar contracture (Fig. 3,
right).
Skin and Subcutaneous Flap Closure
Temporary skin sutures approximate the
skin at the level of the original horizontal line
and 1 inch above and 1 inch below it (Fig. 4,
above, right). The Z-plasty is then marked using
flaps sized similarly to those in the muscle. The
skin flaps can be marked in such a way that the
flaps are interposed opposite to the direction
of the muscle flaps. This is a nicety, not a
necessity. The temporary midline sutures are
removed, and the flaps are incised, elevated,
interposed, and sutured.
Subcutaneous tissue is sutured with Vicryl or
monocryl. A combination of running and in-
terrupted 6-0 nylon is used for skin closure
(Fig. 4, below, center). The desired contour can
be appreciated at the conclusion of surgery
(Fig. 4, below, right).
Dressing
A dry, sterile dressing of the surgeon’s
choice is placed over the suture line, and then
a contoured compression Caromed face lift
bandage with a 2-inch neck extension is put in
place (Fig. 5). An ice bag is placed over the
bandage.
Postoperative Course
The compression bandage is worn continu-
ously for 1 week. The patient is advised to
continue to wear it full time while at home for
2 more weeks, and then to wear it at night as
long as there is any palpable firmness or sense
of tightness to the scar. If the patient does not
wear the bandage faithfully, early temporary
contracture can occur. Contracture can be
avoided with diligent use of the bandage. Su-
tures are removed after 1 week when patients
return to their usual nonaerobic activities.
They are asked to refrain from vigorous activity
for 3 weeks, at which time full activity is re-
sumed. A mild analgesic (propoxyphene and
acetaminophen; Darvocet-N 100) is prescribed.
Most patients switch to acetaminophen (Tyle-
nol) after 48 to 72 hours.
RESULTS
Patients ranged in age from 58 to 75 years.
Face lift patients were generally younger. Fig-
ures 6 through 9 show the results of the pro-
cedure.
Vol. 106, No. 5 / ANTERIOR CERVICOPLASTY IN MEN 1151

FIG. 6. Preoperative (above) and 18-month postoperative (below) views of a 66-year-old retired dentist. (Above, left) The platysma
band is often unilateral, as in this case. (Above, center) Preoperative lateral view. (Above, right) A prominent thyroid cartilage is
more evident in the submental view than it is in the frontal view (above, left), where the platysma is adjacent to it. (Below, left)
The submental view shows a tightening of the entire anterior neck. (Below, center) The postoperative lateral view shows an
improved neck contour and an improvement in the jowl area. (Below, right) The scar is a fine line and hypopigmented.

DISCUSSION patients have a vertical excess of skin. Sec-

This technique differs from the TZ-plasty on
the male “turkey gobbler” neck, which was
originally reported by Cronin and Biggs,1 in
several respects. First, the present technique
does not use a horizontal, elliptical excision
of skin in the submental area, as is described
by Cronin and Biggs.1 I do not think these
ond, the Z-plasty in the platysma muscle was
not used in the original technique1 but was
mentioned by Biggs later.2 He did not de-
scribe either the platysma or the skin Z-plasty
as being done precisely in a manner to estab-
lish the location of the mental/cervical
crease at the level of the horizontal limb of
1152 PLASTIC AND RECONSTRUCTIVE SURGERY, October 2000

FIG. 7. Views of a 55-year-old accountant. The postoperative photographs were taken 1 year after a cervicoplasty and upper
blepharoplasty. This is the same patient shown in Figures 1, 3, and 5. (Above, left) Preoperative frontal view. (Above, right)
Preoperative lateral view. (Below, left) Postoperative frontal view. (Below, center) Postoperative lateral view. (Below, right) Postop-
erative scar.

the Z-plasty. Third, Cronin and Biggs1 lim- Gilbert P. Gradinger, M.D.
ited the lower extent of the midline skin 1635 Divisadero Street
incision to the level of the thyroid cartilage, Suite 625
which necessitated a transverse horizontal San Francisco, Calif. 94115
skin incision in the lower neck. I favor ex-
REFERENCES
panding the incision as far inferiorly as nec-
essary to excise the excess skin. Finally, they 1. Cronin, T. D., and Biggs, T. M. The TZplasty for the
male “turkey gobbler” neck. Plast. Reconstr. Surg. 47:
did not use more than one Z-plasty in the 534, 1971.
platysma to prevent muscle contracture or 2. Biggs, T. M. TZplasty for the male “turkey gobbler”
banding. neck. Plast. Reconstr. Surg. 65: 238, 1980.
Vol. 106, No. 5 / ANTERIOR CERVICOPLASTY IN MEN 1153

FIG. 8. This 67-year-old radio talk show host is shown before (above) and 1 year after (below) a cervicoplasty and upper
blepharoplasty. (Left) Frontal view. (Center) Lateral view. (Above, right) Note the longer-than-usual ellipse necessary to remove
all of the redundant skin. (Below, right) Postoperative scar. Note that it extends below the thyroid cartilage.
1154 PLASTIC AND RECONSTRUCTIVE SURGERY, October 2000

FIG. 9. This 72-year-old retired television executive is shown before (above) and 2.5 months after (below) a cervicoplasty. This
is the same patient shown in the intraoperative photographs in Figure 4. Early postoperative photographs show the quick recovery
that is typical of this surgery when compared with a standard rhytidectomy. Note the breadth of the deformity, as seen above and
below, left. Note how far inferiorly the deformity extends, as seen above, right and below, center. (Below, right) Scar is of good quality
but hyperpigmented.