Deep Neck Contouring Surgery: A Comprehensive GuideDr. Gould Plastic Surgery

Introduction

Deep neck contouring is an advanced neck rejuvenation technique that addresses structures deep to the platysma to achieve a sharper cervicomental angle and a defined jawline. Traditional necklifts primarily tighten skin and platysma, but fullness can persist if deeper structures (subplatysmal fat and submandibular glands) are enlarged or ptotic. By directly reducing these deep structures, surgeons can obtain exceptional neck contours beyond what superficial techniques accomplish. In the past, submandibular gland excision in cosmetic surgery was controversial due to concerns about nerve injury or dry mouth. However, recent series have demonstrated that, with proper technique, partial removal (“contouring”) of the submandibular glands and deep fat is safe and effective, with no long-term salivary dysfunction. This manual provides a detailed step-by-step guide to deep neck contouring focusing on subplatysmal fat removal and submandibular gland reduction, emphasizing anatomical landmarks, dissection technique, nerve and vessel preservation, and measures to maximize safety.

Preoperative Assessment & Indications

Careful patient selection and planning are crucial for deep neck contouring. Key considerations include:

• Neck Anatomy Evaluation – Assess the contribution of fat, platysmal banding, and gland prominence to neck fullness. Patients with a visible bulge in the lateral submandibular region (especially when the neck is at a right angle to the body) are likely to benefit from gland reduction. A useful guideline is to check if the gland visibly protrudes below a line from the mandibular border to the hyoid; a bulge indicates an obvious gland ptosis that will persist without reduction. In “fat necks,” palpation is needed since fat can mask a gland bulge that may emerge after fat removal.
• Indications for Submandibular Gland Contouring – Patients with persistent submandibular fullness despite weight loss or those seeking a sharper jaw-neck angle beyond what liposuction or platysmaplasty alone can achieve are candidates. Often these include older patients with gland ptosis or younger patients with genetically large glands. If a patient has had a prior necklift but still has residual “neck bulges” under the jaw, gland reduction can address what was previously overlooked.
• Salivary Gland Function – It is critical to ensure the patient has no history of xerostomia or major salivary gland disease. Those with pre-existing dry mouth or Sjögren’s, for example, are poor candidates. In practice, surgeons exclude patients with a tendency to dry mouth to avoid compounding any secretory insufficiency. Fortunately, removing or reducing one
• submandibular gland does not usually cause dry mouth because of functional redundancy (the parotids and remaining salivary tissue compensate). Indeed, large series have reported no cases of permanent xerostomia after partial submandibular gland resection.
• Patient Expectations & Consent – During consultation, discuss the scope of surgery – that this is a more involved procedure than a simple lipo or skin excision. Patients should understand the small risk of nerve injury or need for a drain. Emphasize that salivary function will be preserved and show evidence (e.g. studies and your experience) that there’s no significant long-term impact on saliva or digestion. Informed consent should cover potential complications like hematoma, marginal mandibular nerve weakness, or sialocele (saliva collection).
• Photography & Marking – Mark the submandibular triangles (bounded by the digastric muscles and mandible) preoperatively and note the areas of maximal gland fullness. Often, the outline of each submandibular gland can be palpated and marked with the patient upright. Mark the planned submental incision (typically a 3–4 cm transverse line in the natural crease just behind the chin). Also mark any platysmal band midlines if present (for platysmaplasty) and areas of fat excess (central submental vs. lateral). These markings guide intraoperative resection – for example, confirming which submandibular bulge is more prominent to ensure symmetric reduction.

Key Anatomy of the Deep Neck

A thorough understanding of neck anatomy is essential to safely navigate deep neck surgery. Important anatomical landmarks and structures include:

• Submental and Submandibular Triangles – The submental triangle lies between the anterior bellies of the digastric muscles (under the chin), whereas each submandibular triangle is bounded by the mandible (above), anterior digastric (medially), and posterior digastric (laterally). The submandibular gland resides chiefly in the submandibular triangle, with its deep lobe extending around the posterior edge of the mylohyoid muscle.
• Platysma and Deep Cervical Fascia – The platysma is a thin superficial muscle in the neck. Deep to platysma is the investing layer of deep cervical fascia, which splits around the submandibular gland to form its capsule. Notably, the marginal mandibular branch of the facial nerve (CN VII) runs in the plane between the platysma and the investing fascia (i.e. just superficial to the gland capsule) as it crosses the mandible. This means that during subplatysmal dissection, the marginal nerve will be located superficial to the plane of surgery and can be protected as long as dissection stays just outside the gland capsule.
• Subplatysmal (Deep Neck) Fat – There are two principal fat compartments in the neck – supraplatysmal fat (between skin and platysma) and subplatysmal fat (beneath platysma). Subplatysmal fat commonly accumulates in the interdigastric area (submental fat pad) between the anterior bellies of the digastric, and also lateral to the digastrics overlying the mid-portion of the submandibular gland. This deep fat pad contributes to the
• fullness under the chin and is usually approached by direct excision (as liposuction cannot reliably remove fat beneath the platysma). Caution: the volume of subplatysmal fat varies – overly aggressive removal can cause a hollow; thus a graded removal is performed to restore a smooth contour.
• Digastric Muscles – The right and left anterior bellies of the digastric run from the chin (digastric fossa of mandible) to the hyoid bone (where they meet the posterior bellies via an intermediate tendon). In a heavy neck, these muscles may be enlarged or bulky, appearing as a convex ridge beneath the subplatysmal fat. They define the medial boundary of each submandibular gland. After removing the overlying fat, the anterior digastrics become visible as strap-like muscles coursing from the midline back to the hyoid. Hypertrophied digastrics can themselves cause a “double chin” effect and sometimes are surgically thinned (described later). Deep to the digastrics and mylohyoid lies the tongue musculature and the floor of mouth structures, including the submandibular duct and lingual nerve.
• Submandibular Gland – The submandibular gland has a superficial lobe (the bulk of the gland, palpable under the jaw) and a smaller deep process that hooks around the posterior free edge of the mylohyoid muscle into the floor of mouth. The gland is surrounded by a fibrous capsule (derivative of deep cervical fascia) and is located just below the mandible, extending from near the chin back toward the angle of the mandible. Its Wharton’s duct (submandibular duct) emerges from the deep lobe and runs forward above the mylohyoid to drain at the sublingual caruncle. In aesthetic neck surgery, typically the superficial lobe (the part that creates an external bulge) is the target of resection. The deep lobe and duct are left intact to preserve salivary flow.
• Vascular Structures – The facial artery (a branch of the external carotid) runs through the submandibular triangle, often passing deep to the submandibular gland (grooving its deep surface) and then looping up over the mandible’s border to the face. It gives off the submental artery which courses along the underside of the chin. During gland resection, one or more intraglandular arterial branches (sometimes termed a “central perforator” or the submental vessels) will be encountered and must be ligated. The facial vein runs more superficial, typically coursing over or just lateral to the gland and draining into the internal jugular or common facial vein. It is often visible once the gland is exposed; surgeons can usually retract or preserve the facial vein, but if it obstructs access it may be tied off without consequence (venous collaterals accommodate). Small venous branches in the fat or capsule should be cauterized to prevent troublesome bleeding.

Nerves to Preserve: Three cranial nerve branches are in proximity to a submandibular gland excision field:

• Marginal Mandibular Nerve (CN VII) – as noted, this motor nerve to the depressor anguli oris and lower lip runs along (or just below) the mandible. In most individuals, it lies about 1–2 cm inferior to the mandible’s edge as it crosses near the jowl, then even more superior (\~3.7 cm above the gland’s inferior edge) by the time it is over the gland. It is superficial to the gland capsule. Thus, staying deep (intracapsular) during gland resection helps protect it. Care must be taken during lateral retraction of tissues under the jaw so as not to stretch this nerve. If stimulated or injured, the patient could have a temporary lower lip asymmetry (inability to depress the lip ipsilaterally).
• Lingual Nerve (branch of V3) – this sensory nerve runs above the submandibular gland, looping under the submandibular duct in the floor of the mouth. In a submental approach, the lingual nerve is deep and medial to the field and typically not seen. It will be protected as long as dissection stays on the external surface of the gland and does not extend above the gland into the floor of mouth. Lingual nerve injury would cause tongue numbness and taste disturbance, so the surgeon avoids any blind clipping of structures in the deep superior aspect of the gland.
• Hypoglossal Nerve (CN XII) – the hypoglossal motor nerve to the tongue runs deep to the submandibular gland (beneath the gland and stylohyoid/posterior digastric), crossing just inferior to the angle of the mandible on its way to the tongue. It lies even deeper than the lingual nerve, essentially on the deep aspect of hyoglossus muscle. This nerve is usually well below the plane of an intracapsular gland resection and is not encountered if one does not dissect beyond the gland’s posterior-inferior extent. Nonetheless, awareness of its location is important: injury would cause unilateral tongue paralysis. The key is to avoid dissecting too far posteriorly beyond the gland – if the gland is being removed piecemeal and one finds oneself very deep near the hyoglossus, it’s time to stop.

Understanding these anatomical details allows the surgeon to plan safe dissection planes – staying subplatysmal to protect the marginal nerve, staying within the gland’s capsule to avoid deep cranial nerves, and identifying vessels for ligation to prevent bleeding. With this foundation, we proceed to the surgical technique.

Surgical Technique: Step-by-Step Deep Neck Contouring

I. Anesthesia and Patient Positioning

This procedure is typically done under general anesthesia with endotracheal intubation (for airway protection, given the risk of post-op neck hematoma). The patient is placed supine with the neck extended (a shoulder roll can be used) to accentuate the neck anatomy. Ensure the endotracheal tube is well secured, as the head may be rotated during surgery. The submental region and neck are prepped and draped widely to allow access from just behind one earlobe to the other if needed (especially if concurrent facelift incisions are planned).

Local anesthetic with epinephrine (e.g. lidocaine 1% with 1:100,000 epi) is infiltrated along the planned submental incision and into the areas of dissection (subplatysmal plane) to provide hemostasis. Some surgeons also inject a few milliliters directly into each submandibular gland – this can reduce bleeding and the hypertensive response when traction is applied to the gland. Allow time for epinephrine effect (10 minutes) before incision.

II. Submental Incision & Platysma Exposure

Make a horizontal submental incision (approximately 3–4 cm) just behind the chin crease, within a natural skin fold. Dissect through subcutaneous tissue to identify the platysma muscle. Elevate the skin flap off the platysma in the central neck, extending a few centimeters inferiorly and laterally. Importantly, leave a thin layer (≈5 mm) of subcutaneous fat attached to the underside of the skin flap for vascular perfusion. Elevating too close to the dermis can compromise circulation; too deep (into fat) can leave fat on the platysma that obscures landmarks. Aim for a smooth, bloodless subdermal plane.

Next, the medial edges of the platysma muscles are identified. Often there is a separation between the right and left platysma in the midline (which manifests as vertical bands in aged necks). If the platysma does not have a natural separation, create one by incising the platysma in the midline from the chin region down toward the hyoid. This exposes the under-surface of platysma. Using scissors or cautery, continue the dissection under the platysma (subplatysmal plane) laterally into each submandibular triangle. This step effectively “flips up” the platysma like a curtain, giving access to the deep contents. Place retractors (e.g. small Deaver or lighted retractor) to hold the platysma and skin flaps up. In some cases, an additional lateral skin incision (as part of a facelift, behind the ears) is used to assist in retraction and allow contiguous dissection, but a submental-only approach is common for isolated neck contouring.

By the end of this step, you should see the midline structures: the fat between the digastric muscles, the two anterior digastric bellies coursing back on each side, and more laterally, the capsule of each submandibular gland deep in the wound. The anterior belly of the digastric can be palpated as a firm muscle band running obliquely; its intermediate tendon at the hyoid is a useful landmark (just above the hyoid bone at the midline). Identifying the digastric muscle edges confirms you are in the correct plane and helps orient the location of the gland (just lateral to these muscles).

III. Subplatysmal Fat Excision

After platysma elevation, the subplatysmal (deep) fat in the midline is addressed. Typically, there is a pad of fat sitting on top of the mylohyoid muscle, between the anterior digastrics (often called the interdigastric fat pad). There may also be extensions of fat over the anterior surface of the submandibular glands. Gently grasp the fat with forceps and excise it using cautery or scissors. It is often debulked in a conservative, piecemeal fashion – remove fat until you start to see the underlying structures (e.g. the outline of digastric muscles or gland capsule) and then reassess the contour. Avoid aggressive over-resection: leave a thin layer of fat over the digastric muscles if needed to prevent a sunken midline. As a rule, do not create a noticeable concavity; the goal is a smooth convex neck profile. Over-resecting deep fat can cause a “submental depression” that looks unnatural. Conversely, inadequate fat removal will leave residual fullness. During fat removal, use cautery for hemostasis on any small perforating vessels. Typically, small veins traverse the fat from the gland or floor of mouth – coagulate these to keep the field dry.

When the central fat is removed, the anterior bellies of the digastric should be clearly seen on each side of the midline, and the deep cervical fascia over the submandibular glands will be visible laterally (a glistening fibrous layer). Identifying the “digastric triangle” (the area between the anterior digastrics and the hyoid) is important; this is where you will work to access the glands. Ensure hemostasis in the fat layer before proceeding deeper.

At this stage, some surgeons also address the subcutaneous (supraplatysmal) fat if it is excess – often via direct excision or liposuction prior to platysma elevation. However, assuming the goal is deep contouring, we proceed with deep fat removal first. Supraplatysmal fat can be finely adjusted later if needed to feather the neck contour.

IV. Identification of Submandibular Gland & Capsule

With the deep fat thinned, attention turns to the submandibular glands. Each gland lies just lateral to the respective anterior digastric muscle. Retract the anterior belly of the digastric medially (for example, with a small retractor or hook) to improve exposure of the gland area. The capsule of the submandibular gland (investing fascia) will be encountered as a fibrous layer. It may have some residual fat attached. Typically, the medial aspect of the gland’s capsule can be found by following the digastric muscle to its posterior extent (near the hyoid) – just lateral to that point is the gland’s medial capsule. You might also identify the digastric tendon at the hyoid and see the gland capsule lateral to it.

Carefully incise the gland’s capsule on its anteromedial surface using cautery or fine scissors. A 1–2 cm incision in the capsule is enough to begin. Once the capsule is opened, you will see the salivary gland parenchyma, which is a tan/pink lobulated tissue. Now, using blunt dissection with scissors or a periosteal elevator, begin mobilizing the gland within its pocket. The technique is often described as “intracapsular” dissection: rather than dissecting around the outside of the gland (which could endanger nerves), you dissect between the gland and its capsule, essentially peeling the capsule off the gland from the inside. Spread blunt scissors in the plane between gland and capsule – this will break the fibrous septations and free the gland lobules from the capsule.

Proceed systematically: free the inferior aspect of the gland first, then the lateral and superior aspects. Keep the dissection immediately adjacent to the gland substance. Counter-traction is very helpful – you can place an atraumatic clamp (e.g. a Lahey or Babcock clamp) on a portion of the gland to gently pull it outward while you blunt-dissect between gland and capsule. Another hand or assistant can use a retractor on the capsule to provide counter-traction. This push–pull technique greatly aids in defining the plane. Take care near the posterior aspect of the gland – bluntly feel or sweep there, as the capsule is often adherent near the gland’s hilum (where the duct and vessels enter). Do not excessively avulse tissue; if it’s not releasing easily with blunt spreading, use a bit of cautery to detach fibrous strands.

Throughout this step, maintain awareness of where the nerves are: The marginal mandibular nerve is outside the capsule (above), and the lingual/hypoglossal are deep to the capsule (medial/posterior). By staying inside the capsule, you essentially put a layer between your dissection and those nerves. Up to this point, typically no nerve structures are encountered visually, which is expected and desirable.

V. Gland Delivery and Partial Excision

Once the gland is mobilized within its capsule, it can be partially delivered out of the incision for resection. Often the inferior pole of the gland will pop out first. At this juncture, a useful maneuver is using a bone hook on the mandible (hooking the underside of the mandible) to lift the mandible and tissues upward, which in effect presents the gland more into the field. Now assess how much gland tissue is excessive. The goal is usually to remove the superficial lobe of the gland that causes external fullness, while leaving the deep lobe (around the duct) intact. In practice, surgeons often end up removing roughly 40–60% of the gland by volume, flattening it flush with the mandibular border and floor of mouth.

Proceed with parenchymal resection in a controlled, stepwise fashion:

• Using electrocautery (with a fine-tip or needle tip), shave off portions of the gland from its outer surface. Gland tissue is friable, so rather than grabbing and tearing, it’s safer to cauterize through it bit by bit. Some describe taking the gland in piecemeal fashion – resect a portion, obtain hemostasis, then re-grasp and resect more. This incremental approach ensures you always have a clear view of what remains, and you don’t inadvertently cut structures too deep.
• Identify and control blood vessels early. There are typically two sets of vessels: small superficial feeders (from platysma or skin side) and one or more larger perforators entering from the deep side (often from the facial or submental artery). The central perforating vessel (sometimes called the gland’s hilum or central artery) is commonly encountered as you go deeper – it appears when you are roughly halfway through the gland resection. Before cutting it, double-clamp and ligate or clip this vessel if possible. Alternatively, bipolar cautery can be used, but a secure tie or clip is wise for any vessel of significant size to prevent later bleeding. Meticulous hemostasis at this stage cannot be overemphasized – injury to a major gland vessel can be difficult to control in the small space and may lead to hematoma.
• The facial vein often becomes visible during gland resection. It usually runs along the supero lateral aspect of the gland. If seen, decide whether it hinders gland mobilization. Often it can be gently dissected off the gland and left intact. If it is stretched tight or torn, clamp and tie it.
• Continue resecting gland lobules until the remaining gland is thin and flush with the floor of mouth (i.e., you might leave a 0.5–1 cm thickness of gland tissue over the mylohyoid muscle). The exact amount to remove is a matter of judgment: remove enough to eliminate the external bulge, but avoid total gland extirpation which isn’t necessary for contour and carries more risk (complete excision would require dissecting the deep lobe and tying off Wharton’s duct – not typically done in aesthetic cases). In essence, sculpt the gland: the most bulk is usually in the central part of the gland and extending toward the tail (posterior). You’ll focus reduction there for maximal contour improvement, while leaving the part near the duct (anteromedial) undisturbed.
• Handle the gland gently. Rather than grabbing it with tooth forceps (which can tear it and cause bleeding), use atraumatic forceps or the earlier-mentioned traction suture technique. Some surgeons will place a long suture through a portion of the gland and out through the skin (a “percutaneous traction suture”) to pull the gland outward for better visibility. This avoids excessive clamping on the gland tissue. Once the resection is done, that suture can be removed.
• As you resect, keep track of the capsular edges. Often, you can see the tough white capsule lining the cavity where the gland was – preserving this capsule is helpful, as it provides an extra layer protecting the nerves and also can be used for suture anchoring later. If the capsule is very redundant after removing the gland tissue, one can trim excess capsule, but generally at least a portion is left in situ.

Periodically, verify hemostasis by pausing cautery and observing. Have hemostatic agents ready: surgeons commonly use oxidized cellulose pads (Surgicel) or a fibrin glue in the gland bed. Before closing the gland area, many will spray a coat of fibrin sealant to seal any oozing and reduce the risk of postoperative salivary leak (sialocele).

Note on Extent of Resection: Usually only the superficial lobe of the gland is removed, and the deep lobe left intact with its duct. This preserves function and avoids the need to formally isolate and ligate the duct. In some cases of extreme gland ptosis or enlargement, a near-total gland resection might be performed, in which case the surgeon would identify the Wharton’s duct and tie it off near the hilum (and also be cautious of the lingual nerve). However, this is rarely necessary for purely aesthetic cases. The evidence shows partial resection is sufficient for significant contour improvement while completely avoiding lingual or hypoglossal nerve exposure/injury (none were seen in hundreds of cases when sticking to partial intracapsular technique).

VI. Optional: Anterior Digastric Muscle Reduction

After gland resection, re-evaluate the neck contour. In some patients, bulky anterior digastric muscles contribute to a blunted cervicomental angle or residual fullness under the chin. If the digastrics are prominent (they may appear as sausage-shaped bulges under the chin when the neck is flexed), an anterior belly digastric reduction can be performed. This is an optional adjunct – many necklift experts will do this routinely if the muscle is visibly hypertrophied.

The technique involves a tangential excision of a portion of the digastric muscle to debulk it. Usually this is done after the subplatysmal fat is removed and before or after gland work (sequence can vary, but at this point the area is already exposed). To do this:

1. Identify the anterior digastric muscle belly clearly. It runs lateral to the midline; often a portion of it is already exposed.
2. Using an artery forceps or tonsil clamp, grasp the digastric muscle belly midway along its length. Elevate it slightly.
3. Electrocautery is then used to shave off the outer convexity of the muscle. Essentially, you’re thinning the muscle by removing most of its thickness (some literature describes resecting \~90% of the anterior belly). A cutting cautery setting works well to cut and coagulate as you go. Resect from near the midpoint of the muscle belly towards its insertion on the mandible, preserving a small cuff of muscle at the attachment for continued function.
4. Repeat on the opposite side to maintain symmetry. Take care not to damage the intermediate tendon area at the hyoid inadvertently; stay on the muscle belly proper.

In deep neck contouring, a portion of each digastric muscle can be removed with cautery to reduce bulk under the chin. This maneuver is performed through the submental incision after exposing the muscle, and can significantly sharpen the neck profile when digastrics are hypertrophic. Importantly, some muscle near the attachments is preserved (not all fibers are cut) to maintain continuity and avoid functional issues.

Resection of the digastrics should be done conservatively – remove the bulging part of the muscle but do not completely sever it from its attachments. After this, one can often see a noticeable improvement in the neck concavity when viewing the profile. Ensure any bleeding from the muscle edges is controlled (the digastric has minor blood supply, typically easily cauterized). The midline is then inspected; with smaller digastrics and less fat, the cervical menton angle should be much more acute.

VII. Platysma and Neck Muscle Adjustment

With the deep structures (fat, gland, digastric) addressed, the platysma muscle and superficial tissues must be redraped and secured to create a smooth neck contour. Key steps:

1. Perform a midline platysmaplasty if indicated. This involves suturing the right and left platysma edges together in the midline under the chin. Use interrupted or running 4-0 or 3-0 monofilament sutures to approximate the medial borders of platysma from the chin down to the thyroid notch. This accomplishes a tightening of the platysmal sling and helps eliminate any residual banding. (If the platysma was not incised but simply retracted, you may create a midline plication by taking bites of the platysma on each side and tying them together.) This step improves neck definition further by supporting the now-reduced deep tissues and smoothing out the anterior neck.
2. If a lateral neck lift is part of the procedure (incisions around the ears), the platysma can also be tightened laterally. Surgeons often do a platysma posterior suspension by suturing the posterior aspect of platysma to the mastoid fascia, which helps sharpen the jawline. In an isolated submental approach, this lateral step isn’t possible through the small incision – in such cases, the midline platysmaplasty is the primary muscle adjustment.
3. Inspect the contour: sometimes after gland removal, there can be a slight depression or void where the gland was. Surgeons have developed techniques like suturing the deep cervical fascia or capsule to the digastric muscle or tendon to fill the dead space. For example, one can place a stitch from the undersurface of platysma or the cut edge of capsule down to the digastric to tack it, effectively “closing” the pocket where the gland was. Mendelson described partially closing the gland bed by suturing platysma to the digastric tendon to reduce dead space and possibly reduce sialocele formation. This is an optional maneuver but can be beneficial if there seems to be a significant cavity.
4. If there is any residual subcutaneous fat irregularity, it can be addressed now. Sometimes a bit of liposuction is done in the submental area to feather the transition between treated and untreated areas, or a bit more supraplatysmal fat is trimmed.

At this point, the deep neck contouring portion is complete – the undesirable bulges are removed and the supporting muscle layer is tightened. The final steps are to ensure hemostasis and close up appropriately.

VIII. Hemostasis and Closure

Prior to closure, achieve absolute hemostasis. Take a few minutes to inspect all surfaces:

1. Re-check the gland resection sites for any oozing or pulsatile bleeders (the ligated central artery stump should be secure with a tie or clip).
2. Verify no muscle or fat bleeds; use bipolar cautery for any small oozing points on the gland remnant, digastric muscle, or platysma edge.
3. It can be helpful to irrigate with saline and then briefly perform a Valsalva (if under general anesthesia) to see if any venous bleeding starts under pressure – then address it.

Given the closed space of the neck, many surgeons take extra measures to mitigate hematoma and fluid collections:

• Topical hemostatic agents: As noted, placing Surgicel or Tisseel (fibrin glue) over the raw gland surface is common. Fibrin glue in particular can seal off the gland remnant and has been reported to help prevent sialocele (by sealing salivary ducts).
• Drains: It is advisable to place a suction drain in the neck given the potential for dead space and oozing. Typically, one drain is placed in each submandibular region (through separate stab incisions laterally) or a single drain traversing across the submental area. In O’Daniel’s series, drains were used routinely without hematomas. Mendelson initially used drains but later did selective use when partial closure was done. Most would agree a drain for 24–48 hours is prudent to evacuate any blood or serous fluid, thereby reducing risk of compression or sialocele.

Finally, close the incision in layers. If the platysma was cut, suture the platysma muscle layer first (with an absorbable suture like 4-0 Vicryl) to reconstitute the muscle continuity. Then close the subcutaneous tissue and dermis (e.g. with buried 5-0 monocryl and a running 6-0 prolene or nylon for the skin). A meticulous closure will leave a fine line scar hidden under the chin.

Apply a light sterile dressing. Often a mild pressure dressing or neck wrap is applied to compress the dead space gently – but be cautious: the neck wrap should be snug but not tight, to avoid choking the patient or obscuring signs of a potential hematoma.

With that, the surgical procedure is complete. The patient is then awoken and extubated once fully alert and stable.

Postoperative Care and Monitoring

Postoperative management is aimed at protecting the airway, detecting any bleeding early, and managing expected swelling:

• Airway & Bleeding Monitoring: Because a neck hematoma can compromise the airway, it is recommended to keep the patient under observation in a facility overnight. In the first 6–8 hours, closely watch for any neck swelling, difficulty breathing or swallowing, or excessive drain output. A rapid, tense swelling in the submental area with respiratory stridor indicates a surgical emergency – immediate opening of the incision at bedside may be required to decompress a hematoma and secure the airway. Keep a suture removal kit at the bedside (as is done for thyroidectomy patients) in case emergent release of sutures is needed. Fortunately, with meticulous technique the incidence of significant hematoma is low (O’Daniel reported none in 170 cases, Mendelson had 2 in 112 cases).
• Drain Care: Manage drains by stripping and recording output. Typically, drains are removed when output is low (often by post-op day 1 or 2). In some cases of oily salivary drainage or a known sialocele, drains might be left longer. One case of sialocele in O’Daniel’s series was managed with a drain for one week plus Botox to the gland. Generally, once the fluid is minimal and not saliva-like, the drain can be safely removed.
• Pain and Medications: Pain is usually mild to moderate. Deep neck work can cause more soreness when swallowing or moving the neck. Provide adequate analgesia (often oral analgesics suffice after the first day). Prophylactic antibiotics (covering skin flora) are commonly given while drains are in, since an open drain through the skin can introduce bacteria. A broad-spectrum antibiotic for 5–7 days is a typical choice. Dexamethasone in the immediate post-op period can help minimize swelling.
• Head Elevation: Keep the patient’s head elevated (30 degrees) to reduce edema. Instruct them to avoid bending over or heavy lifting for at least 1–2 weeks.
• Activity: Patients should limit neck motion. They must avoid turning the head side-to-side vigorously or extending the neck (which could stress internal sutures). Often a soft neck wrap or collar is used as a reminder to minimize neck movement for the first week.
• Monitoring for Sialocele: A sialocele (saliva collection) typically presents a few days post-op as a painless, fluctuant swelling in the submandibular area. If a swelling appears, differentiate it from a seroma: aspirate some fluid. Saliva will be clear and have high amylase, confirming a sialocele. Most sialoceles resolve with conservative treatment: serial aspiration and pressure. An effective treatment is botulinum toxin injection into the residual gland remnant, which temporarily suppresses salivary output and allows the leak to stop. Mendelson reported using Botox (20 units) in three cases, leading to resolution. Rarely, a persistent sialocele might need reopening and packing, but this is uncommon.
• Follow-up: Typically see the patient 1–2 days post-op for drain removal and wound check, then at one week for suture removal (if non-absorbable sutures were used) or wound inspection. At each visit, assess lower lip motion (have the patient smile or grimace to ensure the marginal nerve is functioning) – mild asymmetry may be present if there was neurapraxia, but this should improve over weeks. Also inquire about saliva – patients nearly always report no change in mouth moisture (reinforcing the expectation that one gland less does not cause dry mouth).
• Patient Instructions: Instruct on wound care (keeping the incision clean and dry for a few days, then gentle washing; no submersion until healed). No strenuous activity or heavy lifting for 2 weeks. They should avoid anything that stimulates heavy salivation (e.g. chewing gum) in the first week if possible, to minimize saliva pooling in the area of the treated gland.

Most patients tolerate the recovery well. By 1–2 weeks, bruising and swelling subside. A minor sense of firmness or fullness under the chin can persist for a few weeks, which is normal post-op fibrosis. Sensation to the upper neck skin can be numb initially (from flap elevation) but returns over a few months.

Outcomes and Benefits

When performed correctly, deep neck contouring yields significant aesthetic improvements. Patients achieve a crisp mandibular border and a more acute cervicomental angle (ideal \~105–120°), as described by Ellenbogen’s criteria for a youthful neck. The jaw-neck definition that was obscured by gland bulges or fatty deposits becomes clean and sculpted. Importantly, these results are long-lasting – once removed, the submandibular gland does not regrow, and fat will not recur in that area as long as weight is maintained. Figures from long-term follow-ups show maintenance of contour even at 10 years, whereas untreated glands may droop or enlarge over time.

Studies and clinical series report high satisfaction and low complication rates:

• In a series of 170 deep neck patients with gland resection, no patient experienced permanent nerve damage or complaints of dry mouth, and only one (\~0.6%) had a sialocele that was successfully treated. Temporary lower lip weakness occurred in a few cases (\~4%), all resolving within weeks.
• Mendelson’s series of 112 patients (with 15% undergoing gland reduction) similarly showed no permanent marginal nerve injuries or lingual/hypoglossal injuries. Marginal mandibular neurapraxia occurred in \~4.5% and fully recovered in all. There were no cases of permanent xerostomia.
• Cadaveric research has illustrated that men, who often have heavier subplatysmal structures, benefit greatly from this approach – one study found male necks had a higher proportion of deep fat and tissue weight than females, meaning addressing the deep plane can be crucial for an “exceptional” result. The authors concluded that achieving an excellent neck contour often “requires addressing structures deep to the platysma”, including gland and fat, and that it can be done safely with detailed knowledge of anatomy.

Another outcome to highlight: by reducing the gland, surgeons avoid the pitfall where a standard facelift/necklift might tighten skin over a bulging gland, actually making the gland more conspicuous post-op (since the skin drapes over it). By performing gland contouring, one ensures that after healing, there is no visible bulge ruining the contour. In fact, omitting gland reduction in someone who needs it can lead to patient dissatisfaction and requests for revision.

Aesthetically, the combination of submental fat removal, digastric tightening, and gland reduction can produce what some call the “hunter’s angle” – a sharp angle under the chin – that is especially prized in profile view. The inferior border of the mandible becomes well-defined from chin to angle, with a smooth transition to the neck. These nuanced improvements elevate a good necklift result to an excellent one.

In summary, the benefits of deep neck contouring are a more sculpted and youthful neck that cannot be achieved by superficial techniques alone. By preserving vital structures and function (saliva, nerve function) while removing unnecessary bulk, it enhances aesthetics without trade-off in physiology.

Critical Safety Considerations & Complications to Avoid

While generally safe in experienced hands, deep neck contouring involves vital anatomy, so a safety-first approach is mandatory. Below are key potential complications and how to minimize them:

• Airway Compromise from Hematoma: The most feared complication is a neck hematoma leading to airway obstruction. Even a small arterial bleed in the confined submandibular space can cause rapid airway compression (as illustrated by a case where a central gland artery bled and caused severe airway obstruction within minutes). Prevention: meticulous hemostasis (identify and tie off the central gland artery, adequately cauterize gland tissue) and placement of drains to evacuate any occult bleed. Post-op vigilance is critical – observe the patient and educate nursing on early signs (neck swelling, stridor). Many surgeons keep patients overnight for this reason. If a hematoma occurs, do not hesitate to reopen the incision at bedside – removing sutures can be life-saving by relieving pressure, and one can control the bleeding vessel once the airway is secure. Having the necessary instruments and lighting available for an emergency re-operation is a wise precaution.
• Injury to Marginal Mandibular Nerve: This nerve is susceptible to traction or cautery injury if one strays too high near the mandible or uses aggressive retraction. Preventive measures: Limit dissection to below the mandible border (the nerve usually stays within 2 cm of the mandible’s edge). Keep traction gentle and intermittent – prolonged or excessive retraction on the mandible/platysma can compress the nerve (retraction injury is thought to be a cause of temporary palsy). Using a nerve monitor is an option, but often not needed if you stay in proper planes. Importantly, by performing intracapsular gland resection, the nerve is not directly exposed at all in most cases. If the nerve does get stretched, the result is a transient palsy: patients might have an asymmetric smile or difficulty depressing the lip. This occurred in a small percentage of cases (2–5%) in studies and all resolved within 1–3 months. Management: reassure the patient – neurapraxia typically recovers. Some surgeons inject a bit of Botox in the opposite lower lip depressor to reduce asymmetry while recovering.
• Lingual or Hypoglossal Nerve Injury: These are exceedingly rare in cosmetic neck surgery, since they lie deep to the surgical field. Injury would likely only occur if one ventured far outside the normal dissection (for instance, blindly clamping something deep to the gland). By leaving the deep lobe of the gland and not dissecting in the floor of mouth, these nerves are naturally protected. To be safe, always know what structure you are cauterizing or cutting – if unsure, do not cut it. For example, if a rounded structure is seen deep and medially (could be the hypoglossal nerve looping), simply avoid it and leave that part of the gland. Conservative resection is better than risking nerve damage. If a lingual nerve injury were to occur, the tongue would be numb on that side; if hypoglossal, the tongue would deviate and atrophy on that side. Such complications have not been reported in the major series, underscoring that they are avoidable with proper technique.
• Salivary Fistula / Sialocele: A sialocele is a saliva-filled cystic collection that can form if salivary gland remnant leaks saliva into the tissue space. In Mendelson’s 112 cases, \~4.5% developed a transient sialocele. O’Daniel had <1% incidence with use of fibrin glue. Prevention: Meticulously cauterize the cut surface of the gland – especially any visible ducts or glandular tissue – to seal off saliva pathways. The use of fibrin sealant spray over the gland bed has been advocated to seal microscopic ducts. Also avoid placing a suction drain directly on the gland bed (because suction might stimulate saliva flow or keep a duct open); instead, place drains more superficial if possible. Identification: A sialocele typically appears a week or two post-op as a soft swelling; aspiration yields clear fluid with high amylase. Management: Most can be managed non-surgically. Aspirate it (which also relieves pressure), apply a pressure dressing, and inject Botox into the gland remnant to temporarily stop saliva production. This approach has a high success rate, often avoiding need for surgical intervention. Anticholinergic medications (like glycopyrrolate) have historically been used to dry up saliva but have side effects; Botox is more targeted and was effective in Mendelson’s experience. Only if a sialocele persists or gets infected would surgical re-exploration be needed (rare). Importantly, these are not true infections (unless secondarily infected); they are benign and will resolve with the above measures.
• Seroma: A pure seroma (non-salivary fluid) is possible given the dead space. Drains largely prevent this. If one occurs after drain removal, aspiration is usually sufficient.
• Infection: Infection risk is low ( <1%) since neck surgeries are clean-contaminated (the oral cavity isn’t entered significantly if done properly). Prophylactic antibiotics are reasonable. If a patient develops increased pain, redness, fever, or purulent drainage, initiate antibiotics and consider opening a portion of the incision to drain any abscess. Culture any fluid. In the rare event of an infected sialocele (salivary abscess), more aggressive drainage and antibiotics targeting oral flora would be needed.
• Contour Irregularities: The surgeon must aim for a smooth, symmetric contour. Pitfalls include:
  • Under-resection: leaving too much fat or gland on one side can cause asymmetry or less than-ideal definition. This might require a touch-up procedure. Avoid by carefully comparing right vs left during surgery; some surgeons sit the patient up under anesthesia to inspect the neck profile before closing.
  • Over-resection: removing excessive fat can create a midline depression, or removing too much gland can cause a hollow or even show a “skeletonized” digastric muscle outline under the skin. It’s better to slightly under-correct than to overshoot. One can always do minor liposuction later if needed, but rebuilding a hollow is difficult.
  • Palpable irregularities: Ensure any sharp edges (e.g., of remaining gland or digastric) are smoothed. This can be done by slight recontouring or by overlaying some residual fat or platysma over them. The capsule can help smooth the gland remnant. In men with very thin skin, be especially cautious of not leaving steps or edges.
  • Scar and Skin Issues: The submental incision usually heals well. Hypertrophic scarring is uncommon under the chin. To reduce risk, handle skin atraumatically and ensure not to strangulate it with tight sutures. If significant undermining was done, monitor skin for any signs of ischemia (which would be extremely rare in this area if one preserved the subdermal plexus by leaving some fat on the flap).

In summary, prevention and preparedness are the twin approaches to safety: prevent what you can by superb technique (knowledge of anatomy, delicate tissue handling, good hemostasis) and be prepared to manage issues (have a plan for hematoma or sialocele). The reported complication rates for deep neck contouring are low and mostly minor. By adhering to the principles outlined above, a surgeon can safely navigate the potential pitfalls of this procedure.