Reply: LigaSure-Assisted Submandibular Gland Excision in Deep-Plane Neck Lift: Review of 83 Patients

I thank the authors for their valuable contribution in response to our article entitled "LigaSure-Assisted Submandibular Gland Excision in Deep-Plane Neck Lift: Review of 83 Patients."1 Their discussion further emphasizes the importance of submandibular gland (SMG) excision in deep-plane neck lifts. It is more valuable to look at this issue from a general perspective rather than considering which device to use in SMG excision. The most important consideration is that SMG excision in a neck lift is now an indispensable element for achieving the ideal aesthetic appearance of the neck. For many years, surgeons have distanced themselves from this surgical step. However, as shown previously, SMG excision is inevitable when pursuing the ideal result in neck aesthetics. The most important problem is the hesitance of some surgeons, especially those new to face lifts, to perform SMG excision. The main reason may be surgical anxiety regarding possible intraoperative bleeding. In the published article, the goal was to use LigaSure, a bipolar coagulation system, to reduce intraoperative bleeding to zero, while providing surgical comfort.1 LigaSure is becoming the most commonly used coagulation system in many surgical specialties today. Its ability to safely seal vessels as large as 7 mm, its availability in almost all surgical centers, and the many scientific articles published on it have led my coauthor and I to use this device in SMG excision. The 83 cases reported in our article have now grown to more than 200, demonstrating how indispensable LigaSure is for us. Unlike LigaSure, the harmonic scalpel closure system generates vibration-based energy through ultrasonic waves at 55,000 Hz to create an endovascular coagulum. The literature demonstrates its effectiveness compared with the conventional monopolar technique in controlling intraoperative bleeding and postoperative pain, especially in vascular organ procedures (eg, thyroid, parathyroid) and in similar surgical specialties.2 In plastic surgery, Deo et al. demonstrated its effectiveness in lifting the pectoralis major myocutaneous flap,3 and Hamahata et al. showed its advantages in the anterolateral thigh flap.4 The closest article to our study is successful superficial musculoaponeurotic system flap lifting in a face lift reported by Firmin et al.5 Both the harmonic scalpel and LigaSure have clear advantages over monopolar and bipolar systems in achieving hemostasis. The question is which of the 2 systems is more effective. LigaSure seals vessels up to 7 mm, and the harmonic scalpel seals those up to 5 mm.2 The SMG intraglandular vessel diameters range between 2 and 3 mm, favoring the LigaSure. In terms of their price to performance ratios, a single session of LigaSure costs about $499 and a single harmonic scalpel session costs about $799, favoring LigaSure. The more frequent use of LigaSure in my country (Turkey) also points to its favorability. Both systems are superior to monopolar systems, but the harmonic scalpel radiates less environmental heat.2 How decisive this difference is regarding lower lip weakness is uncertain, however, given the unclear pathogenesis of postoperative lower lip weakness. Although heat or traction affecting the marginal mandibular or cervical nerves is important, other aspects, including platysma manipulations, innervation variations of the lower lip depressor muscles, and the relationship between the platysma and the depressor anguli oris, must be kept in mind. In summary, the main aim of the LigaSure study was to emphasize the importance of SMG excision in achieving an ideal neck aesthetic appearance. The goal was to use LigaSure to reduce intraoperative bleeding to zero to minimize surgical stress. In terms of device preference now, my coauthor and I think that both the harmonic scalpel and the LigaSure device seem to be effective in reducing surgical stress while preventing bleeding. However, further studies are warranted to evaluate the superiority of LigaSure versus the harmonic scalpel in terms of postoperative pain, drainage, and postoperative lower lip weakness. Until that time, surgeon comfort, equipment availability, and costs should be considered in making a decision. Regardless of the preferred device, correct analysis of the relationships among the platysma, anterior digastrics, deep subplatysmal fat, hyoid fascia, and other deep structures is very important, as is correct intracapsular dissection and assessing the presence of surrounding structures, such as the facial vein. These considerations should always be kept in mind before selecting a device. DISCLOSURE The author has no financial interest or conflicts of interest to declare in relation to the content of this communication.