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Alex Zuriarrain, MD, is back on the podcast to talk about his recent article on the evolution of platysmaplasty, or neck lifts. He joins hosts Keri Stephens and Alison Werner to talk about the surgical and non-surgical procedures in a plastic surgeon’s arsenal, and why the patient evaluation and setting realistic expectation are key to successful outcomes. In this episode, Zuriarrain

  • Breaks down the objectives of the platysmaplasty. He explains the structure role of the platysma muscle. With age, thin women especially, can see banding in the neck. The objective of neck lift surgery is address those bands and basically re-drape the platysma muscle for a more youthful, contoured aesthetic.
  • Explains that during the patient consultation it is important to access all three facial anatomic zones as a whole and treat “everything together as broadly as you can.” Because, as Zuriarrain puts it, “That’s how you’re going to make the most impact for the patient regarding their cosmetic outcome.”
  • Points out that while small changes can still have a positive impact, it’s important to level patient expectations when it comes to neck lift procedures.
  • Talks about the demographics for non-invasive procedures for the neck. Not every procedure is appropriate for every age patient. Zuriarrain says “Honestly, once you get beyond 35, the impact that you’re going to have from a non-invasive treatment modality is not going to be that strong; it can give some improvement.”
  • Discusses why he does not do thread lifts in his practice. He explains the procedure has its issues, including the fact, that over time, the threads can break and cause an asymmetric result. In addition, they can also cause fibrosis or fibrotic scar tissue that can make future neck lift procedures difficult for the surgeon.
  • Champions realistic expectations. Patients often think plastic surgeons can do anything. But Zuriarrain points out, we’re not magicians. So it’s important to set realistic expectations with patients regarding neck lifts and ensure that they are a good candidate. PSP

Dr Alex Zuriarrain
Podcast Transcript

Alison Werner 0:10
Hello and welcome to the plastic surgery practice Podcast. I’m one of your hosts Alison Werner. Today joining me and my co host Keri Stephens is Dr. Alex Zuriarrain, a frequent contributor to PSP. As a board certified plastic surgeon practicing in Miami, he’s done his fair share of neck lifts. He joins us today to talk about a recent article he wrote for PSP about the evolution and platysmaplasty. From the surgical to the non surgical, and explain why he is not keen on thread lifts and why he likes micro neck lifts for the right patient. He also talks about the importance of helping your patient have realistic expectations. There was a conversation with Dr Zuriarrain.

Keri Stephens 0:43
Dr Zurriarrain, thank you for joining us today.

Dr Alex Zuriarrain 0:46
Thank you appreciate you having me on again.

Keri Stephens 0:49
So you recently wrote an article about the neck lift or platysmplasty. And we want to delve into this a little more. So what are the primary objectives of traditional platysmaplasty? And how does it improve the appearance of the aging neck and jawline?

Dr Alex Zuriarrain 1:05
Yeah, so the primary objective of the platysmaplasty is to try to basically do neck tightening, we’re trying to use the platysma muscle, which is the largest neck muscle, it’s a fan shaped structure that starts right along the jawline, which is basically the mandible, that border and it fans itself all the way down to your clavicles. And that is a very large muscle, we use it every day and facial expression. You know, when we strain lifting heavy objects, or you know, some you know, a lot of physical activities, you know, you see a lot of people have some, sometimes a lot of banding, they’re kind of straight lines of muscle that form over the years. And a lot of times you can see that in women that are sometimes very thin, for example, because there’s no fat in the neck. And you can kind of see those lines popping up. And those are potential bands that when we do necklift surgery, part of the objective is to sometimes we have to cut those bands to release them so that they don’t trigger or activate anymore. And then other things that we do are we come from the side of the neck, and we actually pull back on the platysma muscle and we we stretch it using some very particular suturing styles and techniques and materials to basically re drape the platysma muscle to just get a much more youthful, contoured aesthetic result.

Keri Stephens 2:33
So could you elaborate on the concept of combining necklift procedures with other surgical lifts like facelifts and brow procedures? And how does this combination benefits suitable candidates?

Dr Alex Zuriarrain 2:44
Yeah, so whenever you’re going to evaluate a patient regarding their facial aesthetics, you want to break it down into simple terms for everybody to understand. And the way that I was trained to do that was to divide the face into three separate structures. So if we look at the first structure, we’re looking at basically the hairline to the eyebrows. And so when we’re looking at that section, we’re talking about options such as brow lifts, Botox, and now with the advances that we have, in terms of non surgical approaches, we can enter into the world of microneedling with radiofrequency treatments. For example, the brand name, Morpheus8 is now very common, and that can help rejuvenate the brow. There’s also lateral brow lifts if women have kind of sagging of their lateral eyebrows that are causing hooding overtop of their eyes, you know, when you’re looking at the forehead, those are some of the major options. When you go to the second zone of the face, you’re looking pretty much from the eyebrows to the base of your nose. And there we talked about doing eyelid surgery. So the blepharoplasty is sometimes we do facial fat grafting to the cheeks because they’re hollowing out over time. And then the third part of the face is pretty much from the base of the nose all the way to your clavicles. And that’s where we get into the jowls, the marionette lines, we get into the excess skin of the neck or excess fat of the neck. And we also get into the buccal fat pad surgery which is the excess of fat in the in the cheek area. So when you’re looking at somebody, a patient in consultation, you want to take all of these three facial anatomic zones. And you want to try to treat everything together as broadly as you can. Because that’s how you’re going to make the most impact for the patient regarding their their cosmetic outcome. If you just do very small changes. It’s it’s it’s gonna be positive, but your expectations need to be leveled according to the interventions that you’re having done. And also your anatomy like what is your baseline anatomy? And that that that is king, regardless of whatever cosmetic surgery you’re going to do, you always have to go back to your anatomy as a person, your measurements, your skin quality, all of that.

Alison Werner 5:10
You mentioned there, Morpheus8, and also the microneedling is kind of that non invasive or non surgical technique. Can you talk a little bit more about? Are there other options there on that non surgical side? Or, you know, just your feelings around that approach?

Dr Alex Zuriarrain 5:27
Yes, I think that the non surgical approaches definitely have their demographic, they have the right patient, all about all this. As you know, all of this is about patient selection. So we want to be able to select the appropriate patient for the appropriate procedure. Regardless, if it’s invasive or non invasive, when we’re talking non invasive options, we’re talking about patients between their early 20s All the way maybe you can say for some of them in their mid 30s. Honestly, once you get beyond 35, the impact that you’re going to have from a non invasive treatment modality is not going to be that strong, it can give you some improvement. But for the most part, at that point, you’re talking about, you know what we were speaking about a few minutes ago, which is basically the more not the more invasive facelift and neck lifts, eyelids, brow lifts, etc. So for the younger patient population that you know, is interested in avoiding scars, you know, they want to do non invasive treatments, you know, the earlier you started, the better, quite honestly, because you’re just slowing down the aging process. And I don’t, it doesn’t matter to me if you’re 22, or you’re 25, or you’re 30. I mean, if you’re 22, like good for you, like I applaud you for caring about the way that you look, I applaud you for being presentable. I applaud you for trying to slow down your aging, and having the foresight to do that at 22. But most people don’t most people wait till 42. And then they want to look like they were 22 using non invasive surgical devices, that just they just don’t have that power. Right. So maybe one day, they will maybe one day, some genius, you know, will come up with, you know, that type of device. But for now, really the number one best seller is going to be Morpheus8, you know, regarding microneedling with, you know, penetrating radiofrequency into the first three to four millimeters of the skin. Which by the way, up until today, that’s pretty much been the deepest, you know, surface treatment that has been offered.

Alison Werner 7:45
Okay. Well, in the article, you also mentioned the use of thread lists for the neck for neck rejuvenation. So how do these types of how does? How did these types of sutures, you called them a absorbable, barbed sutures? How do they work? And how do they stimulate collagen production and lift neck tissues, because you also mentioned that in the article.

Dr Alex Zuriarrain 8:06
Yeah, so I do mentioned that in the article. And I wanted to mention it as one of the treatments that are out there. But let me just put a big but on that. I don’t recommend doing them. I personally don’t do any threads. Part of it is that a lot of those threads can have a few a handful of problems. One is that they can eventually over time, either they can break and cause an all of a sudden an asymmetric result. So I can put a thread over here and a thread over here, but they’re not permanent threads. Over time they do they can degrade and they can you know, they can lose their strength. And so you can get an asymmetric result, sometimes you can actually see almost like a purse string, you can see like an actual vector like an abnormal vector of pool. And that will obviously look very odd. And then yes, they can stimulate collagen production. But the negative, the negative side of that is that they can also cause a little bit of fibrosis or fibrotic scar tissue, where they’re being pushed into and placed. So in the future, when we all are going to need a neck lift and a facelift, whoever goes in there, whatever surgeon goes in there and lifts all of this tissue up is going to find themselves with these, you know with some fibrosis, and you know, and some tracks there where the threads were, and that can negatively impact your surgery. So by and large, I’m not a big fan. It’s been a little bit of a kind of a popular thing, but I don’t think it’s really reached major major popularity because a lot of us plastics board certified plastic surgeons are not really pushing those threads.

Keri Stephens 9:52
So let’s get into micro neck lifts that you highlighted that in the article is a popular option. Can you explain exactly what these entail and why there are benefits that people are happy with them once they’ve undergone them.

Dr Alex Zuriarrain 10:05
Yes, I actually did that this week I did a what we would call a mini neck lift or you know, micro neck lift. Basically, it’s just trying to use a smaller incision to get the same results of a neck lift and trying to hide that incision so that it’s less noticeable. Now, caveat, red flag, not everybody is a candidate for this, you have to be evaluated, you have to see how much neck skin laxity you have, you know, what your you know, how old you are, how much weight loss, weight gain, your skin quality, texture, all of those things, because just because they offer or some surgeons offer a mini neck lift or a mini facelift doesn’t mean that you’re going to be a candidate for it. So again, the importance of a physical examination cannot be understated physical examination in person is way better than a virtual consultation. But sometimes we don’t have options there. So we have to do virtuals. And on the last one on the list is a picture consultation. Because that’s never going to be as beneficial than a video. But overall, yes, it just depends. I do love the surgery in the right person, because it barely leaves any incision mark, it’s really hidden behind the ear, for like 99% of it is behind the ear, maybe just a little bit underneath the lobule. And so with that technique you can make, you know, you’re mainly just focusing on the neck, you’re not doing anything to the face. And that’s another important thing to mention. You know, some some people, they they want to do mini, you know, whatever mini neck mini face, but the the more minimalistic you are, the less of a transformation you’re going to get. So you have to take that into account.

Keri Stephens 11:53
No, that makes sense. I want to get back into the patient selection, because you were mentioning, you know, who was not good for the micro necklift? Can you discuss who is who is the ideal candidates for platysmaplasty, you know, both surgical and non surgical and the importance of, you know, keeping patients expectations realistic for the outcomes.

Dr Alex Zuriarrain 12:11
Yeah, realistic expectations, isn’t my bread and butter is what I do all day, every day. There isn’t a day that goes by in my in my clinic that I’m not talking about maintaining realistic expectations. And what happens in plastic surgery, I think is that people forget that it’s as equal to any other medical specialty that everybody expects, is, you know, has potential complications, cardiology, you know, internal medicine, infectious disease, you know, everybody goes to those doctors with the understanding that they’re not magicians, but then they come to plastic surgery, and they’re like, oh, but no, but like, you know, this is what I want to look like. And you know, you can’t achieve this, like, you know, who are you like, no, no, no, I am human. And this is not magic. So you know that that conversation is very important to have regarding platysmaplasty, if you’re going to be a good candidate, you’re typically going to have either platysma bands, you know, those vertical lines that are, you know, running up and down, you’re just going to have basically an aging neck, you’re going to be your 40s or above, you’re going to have you know, laxity, their weakness of the of the of the platysma muscle. And, you know, when you, when you look at yourself in a full profile view, you’re going to have blunting of what we call the cervical mental angle. So the angle that traces from the, the jaw right underneath the jaw all the way down to your voice box, like that curvature should be a nice curve there, you shouldn’t have a blunting of it, meaning, you know, it should have a nice flow to it, it shouldn’t be completely flat cross because that shows that either you have too much fat in the neck, you have a weak little muscle, or you know, you have too much skin that’s just sagging. So again, what you know, a prime example of a massive weight loss patient, you know, they’ve done gastric bypass, and they’ve lost 50 pounds, those patients are going to have a tremendous amount of excess skin in the neck. And a lot of times because of their weight loss, they don’t even have fat in there. There’s nothing really to take out regarding the fat. It’s just platysma tightening, skin tightening, and they look like a totally different person in a positive way amazingly different.

Alison Werner 14:27
Well, I’m curious as we wrap up, what is kind of, you know, what are your what are the things that spark your curiosity or that you look towards the future when it comes to these neck procedures, whether it’s the non invasive or it’s the surgical, what are you looking ahead to that excites you?

Dr Alex Zuriarrain 14:43
I’m excited about the non invasive aspects of it. I think that as surgeons, we’ve been in the invasive world for for for millennia. I mean, you go back to the Egyptians, and being the first you know, rhinoplasty surgeons. They’ve been opening up noses forever. And as plastic surgeons, I think we’re pushing the envelope on what is the non surgical realm of possibility. You know, I have a Morpheus8 device because I, I’m really excited about what it can do. And I’m excited for further evolutions of that type of penetrating microneedle radiofrequency delivery, I’m excited to see if we can go from radiofrequency into some other form of energy that is going to be even more effective, but still going to have a very safe safe outcome with very low minimal complication rates, but maybe, you know, instead of radiofrequency, it’s going to be nano frequency, I don’t know, but something that may actually more deeply penetrate the tissue without burning anybody without causing negative side effects. But at the same time, while providing you know, very, very nice results, you know, I would love to extend that age bracket, you know, of people that can do non invasive treatments, instead of you know, 35, you know, to maybe 45

Alison Werner 16:07
Great, thank you so much for sharing your thoughts and going a little deeper on this article. We really appreciate Dr Zuriarrain.

Dr Alex Zuriarrain 16:13
thank you both. It’s always a pleasure to be on with you. Appreciate it. Keep up the good work. Thank

Keri Stephens 16:16
you. As always, thank you for joining us and be sure to subscribe to the plastic surgery practice podcast to keep up with the latest episodes. And also please check out plastic surgery for the latest industry news. Until next time, take care