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The Submental Fat Compartment of the Neck

Article  in  Seminars in Plastic Surgery · November 2009

DOI: 10.1055/s-0029-1242180 · Source: PubMed

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 The Submental Fat Compartment of the Neck
Daniel A. Hatef, M.D.,1 John C. Koshy, M.D.,1 Safa E. Sandoval, M.D.,1
Anthony P. Echo, M.D.,1 Shayan A. Izaddoost, M.D., Ph.D.,1
and Larry H. Hollier, Jr., M.D., F.A.C.S.1

ABSTRACT

The anatomic understanding of the superficial compartments of the head and

neck are evolving. Recently, studies have shown that the superficial fat is sequestered into
separate ‘‘compartments’’; however, the superficial anatomy of the submental region of the
neck has yet to be defined, and improved understanding of this area may lead to advances in
our ability to rejuvenate the neck. This cadaveric investigation revealed that there is one
superficial fat compartment in the submental region. The anterior boundary of this
compartment, previously without name, has been labeled the ‘‘submental septum.’’ The
posterior boundary of the submental fat compartment is created by a septum that arises
from the platysma at a point superficial to the hyoid. Because this area is over the hyoid, it
has been named the ‘‘suprahyoid septum.’’ The lateral septal boundaries have been labeled
the ‘‘digastric septae.’’

KEYWORDS: Submental fat, fat compartments, neck rejuvenation, submentoplasty

A dvancements in anatomic knowledge have submental region. Just as knowledge of the soft tissue
played a major role in the refinement of many rejuve- composition of the face has led to the refinement of
native procedures. Face-lift surgery, for example, has facial rejuvenation techniques, similar knowledge of the
progressed a great deal since reports of the first rhyti- submental region should be useful in the field of neck
dectomy1,2 because of a more accurate understanding of rejuvenation.
the vascular, muscular, fascial, and subcutaneous com-
ponents of the face.3,4 Facial anatomy has advanced more
recently with the demonstration that the superficial fat of MATERIALS AND METHODS
the face is not composed of one homogenous layer but is A cadaveric study was designed to investigate the anat-
segregated into discrete fat compartments by fascial omy of the submental region using three fresh cadaveric
septae.5,6 heads. All heads were dissected within 5 days postmor-
Changes in the appearance of the submental tem. Methylene blue dye was mixed with normal saline
region also play a crucial role in aging; however, under- in a 1:1 ratio, and this was injected subcutaneously just
standing of the superficial layers of this region is lacking anterior to the submental crease in three heads. Addi-
when compared with the detailed knowledge of super- tionally, the external carotid artery was dissected and
ficial facial anatomy. This deficit in understanding cannulated with a 20-gauge butterfly needle. Latex was
formed the impetus for an analogous investigation into then warmed and mixed with blue dye and injected into
the subcutaneous and soft tissue architecture of the the dissected vasculature. Subsequently, subcutaneous

1
Division of Plastic Surgery, Baylor College of Medicine, Texas Contemporary Face-lift Techniques; Guest Editor, Larry H. Hollier,
Children’s Hospital, Houston, Texas. Jr., M.D., F.A.C.S.
Address for correspondence and reprint requests: Larry H. Hollier, Semin Plast Surg 2009;23:288–292. Copyright # 2009 by Thieme
Jr., M.D., F.A.C.S., Professor and Program Director, Division of Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001,
Plastic Surgery, Baylor College of Medicine, Texas Children’s USA. Tel: +1(212) 584-4662.
Hospital, 6621 Fannin, MC-CC610.00, Houston, TX 77030 DOI 10.1055/s-0029-1242180. ISSN 1535-2188.
(e-mail: larryh@bcm.edu).
288
 SUBMENTAL FAT COMPARTMENT OF THE NECK/HATEF ET AL 289

Figure 1 Anteroposterior view of the submental compartment bounded anteriorly by the submental crease and posteriorly by
the submandibular angle.

dissection was undertaken to expose the methylene blue– anteriorly by the submental crease and posteriorly by the
stained fat in relation to the surrounding vascularity. cervicomandibular angle (Figs. 1 and 2). Laterally, the
compartment is bounded by what appears to be a caudal
continuation of the labiomandibular fold, located just
RESULTS medial to the lateral jawline (Fig. 3). Additionally,
The cadaveric investigation demonstrated a distinct injection of the latex solution into the external carotid
subcutaneous fat compartment highlighted by methyl- artery highlighted the submental artery perforators
ene blue dye injection. The compartment is bounded (Fig. 4). The anterior boundary of this compartment,
previously without name, has been labeled the
‘‘submental septum.’’ The posterior boundary of the
submental fat compartment is created by a septum that
arises from the platysma at a point superficial to the
hyoid. Because this area is over the hyoid, this has been
labeled the ‘‘suprahyoid septum.’’ The lateral septal
boundaries have been labeled the ‘‘digastric septae.’’

DISCUSSION
The results of this cadaveric study indicate that the
submental fat compartment is a discrete areolar chamber
residing within the preplatysmal fat. Superficially, the
compartment is bounded by the dermis, and its deep
boundary is the platysma. The submental crease is
formed by the submental septum and creates the anterior
or mesial border, and the distal or posterior border is
formed by the hyoid septum. The digastric septae
formed the lateral borders of the compartment. These
facts must be translated into a visual and conceptual
understanding of the anatomy of the region to be fully
utilized.
The understanding of the anatomy of the neck
Figure 2 Lateral view of the submental fat compartment. and submental region is constantly evolving. Generally
290 SEMINARS IN PLASTIC SURGERY/VOLUME 23, NUMBER 4 2009

Figure 3 Laterally, the compartment is bounded by what appears to be a caudal continuation of the labiomandibular fold,
located just medial to the lateral jawline.

speaking, the boundaries of the neck are the mandible assessing the degree of ‘‘turkey gobbler’’ deformity in
superiorly, the clavicles and sternum inferiorly, and the submental region based on changes with the skin,
the anterior borders of the trapezoids laterally. Looking fat, platysma, and underlying bone.9 This classification
at the submental region in particular, the deep layers method serves as an invaluable tool in evaluation and
are formed by muscle and fascia, and a subcutaneous layer subsequent intervention.
of fat lies over these deep structures. This superficial layer Various facial rejuvenation techniques have been
of fat is divided by the platysma, a caudal continuation of designed to address the aging process of the neck and
the superficial muscular aponeurotic system (SMAS).7 submental regions. In general, if rejuvenation is also
The anatomy of the fat superficial to the SMAS/super- required in the face, a rhytidectomy is indicated; how-
ficial cervical fascia has not been extensively investigated ever, if the problem is primarily located in the submental
but has been most recently characterized as being seques- region, interventional options include injectable fillers
tered into different ‘‘compartments.’’5,6 (including autologous tissue), laser resurfacing, liposuc-
Rohrich et al noted that fat within the superficial tion, and excisional methods. Regardless of the method
subcutaneous layer of the face is not located in one employed, a thorough understanding of the submental
confluent layer but is actually compartmentalized.5,6 fat compartment will hopefully improve upon all of these
The borders of the compartments are formed by fascial techniques.
septae that travel from the deep fascia or periosteum and A thorough understanding of the submental
insert into the dermis.6 These compartments provide a fat compartment will be valuable to plastic surgeons.
new method of viewing the aging face and neck as Knowledge of where fascial septae lie within the
resulting from variable changes in volume and position subcutaneous layer will facilitate navigation around im-
in the various compartments. This report presents a portant structures. Also, this information is helpful
continuation of that concept, defining the properties of because it alters our perception and understanding of
a previously undocumented fat compartment: the sub- aging in the face, which can potentially lead to better
mental fat compartment. methods to treat the process of aging. Additionally,
The submental fat compartment plays an impor- improved understanding of the anatomy of the region
tant role in the appearance of the youthful and aesthetic can aid in identification of the submental artery and
neck,8 as well as in the overall attractiveness of the its cutaneous perforators and possibly the location of
face. Bitner et al developed a classification scheme for regional lymphatics.
 SUBMENTAL FAT COMPARTMENT OF THE NECK/HATEF ET AL 291

Figure 4 Injection of the latex solution into the external carotid artery highlighted the submental artery perforators.

The cadaveric study demonstrates that the sub- 2. Joseph J. Hangewangenplastik (Melomioplastik). Dtsch Med
mental artery perforators travel within the borders of the Wochenschr 1921;47:287
submental fat compartment in the location of the con- 3. Schuster RH, Gamble WB, Hamra ST, Manson PN. A
comparison of flap vascular anatomy in three rhytidectomy
fluence of the submental septum and the digastric sep-
techniques. Plast Reconstr Surg 1995;95:683–690
tum. This is consistent with what has been demonstrated 4. Gamble WB, Manson PN, Smith GE, Hamra ST.
previously.5,6,10 Additionally, because the artery travels Comparison of skin-tissue tensions using the composite
superficial to the submandibular gland, it is possible that and the subcutaneous rhytidectomy techniques. Ann Plast
this surface anatomy could be used to facilitate location of Surg 1995;35:447–453; discussion 453–454
the gland.11 Finally, superficial lymphatics may be housed 5. Rohrich RJ, Pessa JE. The fat compartments of the face:
within these walls, thus explaining the rapid dissipation anatomy and clinical implications for cosmetic surgery. Plast
Reconstr Surg 2007;119:2219–2227; discussion 2228–2231
of methylene blue dye in these areas.
6. Rohrich RJ, Pessa JE. The retaining system of the face:
This report demonstrates the results of cadaver histologic evaluation of the septal boundaries of the
dissections and adds to the literature of facial and neck subcutaneous fat compartments. Plast Reconstr Surg 2008;
anatomy. The information can be used to improve upon 121:1804–1809
clinical understanding, classification schemes, surgical 7. Vistnes LM, Souther SG. The platysma muscle. Anatomic
technique, and other therapeutic efforts in this region. considerations for aesthetic surgery of the anterior neck. Clin
It will be interesting to see how these advances will affect Plast Surg 1983;10:441–448
8. Ellenbogen R, Karlin JV. Visual criteria for success in
how we view and alter the aging process as it affects this restoring the youthful neck. Plast Reconstr Surg 1980;
region. Further studies that analyze the changes in the 66:826–837
fat compartments with motion and with aging will 9. Bitner JB, Friedman O, Farrior RT, Cook TA. Direct
further augment the contemporary understanding of submentoplasty for neck rejuvenation. Arch Facial Plast Surg
this aesthetically important area. 2007;9:194–200
10. Schaverien MV, Pessa JE, Rohrich RJ. Vascularized
membranes determine the anatomical boundaries of the
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