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premature skin aging [15]. Other important factors which contribute to the aging of the skin include skin type, history of sun exposure, history of skin irradiation, hyper or hypo thyroidism, diabetes, peripheral vascular disease, atherosclerosis, and liver failure. Not only do the afore mentioned factors contribute to skin aging, but they may also influence the degree of surgical correction performed by affecting the viability of skin flaps. Ameliorating factors, such as retinoic acid use, routine skin care, and sun protection may serve to retard the aging process. 59.4 Evaluation of the Aging Neck 59.4.1 Analysis and Classification Previous authors have described visual criteria for the youthful neck which include [16]: 1. Distinct inferior mandibular border from mentum to angle without jowl overhang 2. Subhyoid depression 3. Visible thyroid cartilage bulge 4. Visible anterior border of the sternocleidomastoid muscle distinct in its entire course from the mastoid to sternum 5. Cervicomental angle between 105° and 120° Another classification system in use is that proposed by Dedo [17]: Class I: Minimal deformity: well-defined cervicomental angle, good platysmal tone, no fat accumulation. Class II: Early cervical skin elastosis, no fat accumulation, no platysmal weakness. 656 H. Mittelman and J.D. Rosenberg Class III: Early cervical skin elastosis, fat accumulation, no platysmal weakness. Class IV: Platysmal muscle accentuation with banding present either in repose or on contraction. Class V: Congenital or acquired retrognathia/ microgenia Class VI: Low hyoid. While classification systems serve as useful tools to compare patients and provide goals for rejuvenation, it must be stressed that analysis and treatment should be performed as an individualized approach for each patient, according to his or her personal pathology. 59.4.2 Physical Findings While patients routinely have a complete facial analysis, this discussion focuses only on findings pertinent to the aging neck. It is important to view the neck as part of the patient’s global appearance. To this end we use a comprehensive facial analysis form for all patient consultations (Fig. 59.1). Addressing the neck at the expense of other facial pathology can lead to postoperative imbalance, an unnatural look, and patient dissatisfaction. Visual inspection begins with assessment of skin quality, which includes dyschromias, static horizontal furrows, and skin lesions such as nevi and skin tags, or acrochordons. Palpation also plays a fundamental role in assessing pathology. Skin elastosis may be visually estimated, but palpation helps confirm the extent of tissue laxity and position of the submandibular glands. 59.5 Jowl/Mandibular Evaluation Starting in a superior to inferior fashion, evaluation of neck pathology begins with assessment of the chin– mandibular line. On lateral view, the pogonion is the most anterior projection of the chin. The ideal location of the pogonion is tangential to a line perpendicular to the Frankfurt horizontal from the vermilion border of the lower lip [18]. If a patient is in normal Class I occlusion (mesobuccal cusp of the maxillary first molar interdigitates with the buccal groove of the mandibular first molar), and the pogonion is posterior to this line, the mandible is hypoplastic. While a man’s ideal pogonion position is tangential to this line, a woman’s ideal position may lie 1–2 mm posterior. In addition, the mentolabial sulcus should lie approximately 4 mm posterior to a vertical line from the lower vermilion border to the pogonion [19]. A hypoplastic mentum may be the result of microgenia, a small chin that results from underdevelopment of the mandibular symphysis, or from micrognathia, which is the result of hypoplasia of various parts of the jaw [20]. Alloplastic implantation is indicated for a hypoplastic mentum in patients with normal or near-normal occlusion. Although the development of a hypoplastic mentum is largely determined by genetic factors, the development of a prejowl sulcus is more the result of aging. However, the prejowl sulcus, or antigonion notch, may also be congenital and be present from childhood [21]. A combination of progressive soft tissue atrophy and gradual bony resorption of the inferior mandibular edge immediately anterior to the jowls (anterior mandibular groove) results in the development of a groove between the chin and the remainder of the body of the mandible [22, 23]. This is known as the prejowl sulcus [24]. With continued aging, the prejowl sulcus may merge with the commissure–mandibular groove, or “Marionette line,” further accentuating a classic sign of the aging jawline. Correction of the prejowl sulcus may be accomplished with alloplastic implantation with the Mittelman PreJowl Implant, or submuscular placement of filler substances, such as hyaluronic acid or hydroxylapatite. Immediately inferior to the mandibular border, lying just anterior to the angle of the mandible, are the submandibular, or submaxillary, glands. With advancing age, glandular ptosis is common and failure to recognize this pathology may compromise the aesthetic cervico-mandibular contour. It is important to point out prominent and ptotic submandibular glands to the patient during the preoperative consultation. While the primary author does not routinely address ptotic glands, a variety of treatment options exist. De Pina and Quinta [25] advocate gland

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