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Neck Lift



Overview

Example of neck suspension technique. Notice the dramatic improvement of both neck angle and jaw line. Click to enlarge.

The effects of aging show early within the neck region. The skin begins to hang loosely and the muscles underneath lose their tone. These changes produce the characteristic look of the aging neck. If you look at any young person who is not overweight you will see that the skin is closely adherent to the neck creating a very sharp angle at the level of the Adams Apple. This angle is called the cervico-mental angle and makes a profound impact on the appearance of the neck.

Notice how the cervical-mental angle is restored from essentially a hanging flat line to a more youthful angle.

In youth, the cervico-mental angle is very sharp approaching 70 degrees. As one ages or gains weight, this angle becomes flatter and flatter for different reasons. With aging, both the skin and the muscles become lax. The muscles form cords that draped down from the chin giving the characteristic turkey neck appearance.

With weight gain, the angle flattens because of the excess subcutaneous fat. The treatment for these two problems is completely different.

face-lift-2
Notice the characteristic banding of the plastyma muscles in the Before. This turkey neck appearance is eliminated in the After. Also notice the improved jaw line and marked reduction of jowling. Click to enlarge.

In the case were the cervico-mental angle has flattened because of fat accumulation within the subcutaneous tissues, most plastic surgeons can normally improve the neck contour with liposuction, with or without a neck lift. When liposuction is performed on the neck two things happen. One, the subcutaneous fat is removed and two, during the healing process the skin redrapes more tightly against the neck creating a leaner appearance with a sharper cervico-mental angle.

The process of facial aging is described more thoroughly below and within the pages describing face lift. The key to neck lift surgery is to tighten the underlying muscles that have become lax, re-create a sharp cervico-mental angle, create a well-defined jaw line, and then redrape the skin to accommodate the new contour. It is important to understand that the majority of the work needs to be done underneath the skin level. It is not just a skin tightening procedure.


Above picture demonstrates how the platysma muscle is suspended under the jaw bone giving a well defined mandibular border as well as creating a youthful neck angle. Midline platysma muscle suture eliminates Turkey Neck.


It is a very exciting time in plastic surgery because we are just beginning to "solve the puzzle" of facial aging. Even though facial aging affects the entire face and neck, sometimes a patient is really only concerned with a particular area such as the neck. In this situation, only the neck needs to be addressed. Often the patient will return to have their face and eyes done when they are ready. This is an excellent way to approach facial rejuvenation. You should only have corrected what really bothers you. You can always come back and have other things done.

Benefits

The benefits of neck lift surgery are the rejuvenation of the neck and the re-creation of a sharp, youthful cervico-mental angle. Here is a brief list of the benefits provided by neck lifting:

  • Re-creation of sharp neck (cervico-mental) angle.
  • Rejuvenation of neck.
  • Dramatic reduction or elimination of turkey neck banding in neck.
  • Defining the jaw line like that seen in the youthful neck.
  • Dramatic improvement or elimination of lax skin and wrinkles within the neck.
  • Correction of double or triple chin.
  • Creating a longer more elegant appearing neck.
  • Scar placement can be done completely behind the ear, virtually unnoticeable.


Incision is positioned within the crease behind the ear making it unnoticeable even when the hair is styled back. A second small incision is placed in the crease below the chin. It, too, becomes almost unnoticeable with time.


Are you a good candidate?

Anyone who has acquired a lax neck where the skin no longer holds tightly against the "Adams Apple" is a good candidate for a neck lift. Despite the fact that aging affects the entire face, it is not uncommon for the neck to show the effects of aging earlier than that of other areas. Therefore, depending on your situation only a neck lift may be required to obtain the degree of facial rejuvenation you are looking for. Here is a brief list of good candidates for neck lift surgery.

  • Lax neck skin.
  • Turkey neck banding within the neck.
  • Loss of sharp neck (cervico-mental) angle.
  • Loss of jaw definition.
  • Double or triple chin.
  • Your neck looks shorter and older than it used to.


Problems Correctable With Neck Lift


Possible complications

The most common complication after neck lifting is inadequate resuspension of the neck tissues. Other risks include asymmetry, nerve injury, infection, blood and fluid collection, and unfavorable scarring.

Do's and Don'ts prior to surgery

  • Medications. Certain medications thin your blood and should not be taken within three weeks of surgery. The most notable is aspirin and aspirin containing products. Vitamin E and many herbal products also thin the blood and should not be used within 3 weeks of surgery. Your plastic surgeon will go over this more thoroughly prior to the procedure.

  • Sleep. It is important to get a good night's rest prior to the procedure. If you think this may be a problem, please, do not hesitate to ask your doctor for something to help you sleep.

  • Smoking. Do not smoke within 3 weeks before and after surgery. Smoking has a profound effect on reducing wound healing capabilities. It significantly increases the likelihood for infection, wound healing problems, and scar formation. It also affects your airway, therefore, makes anesthesia much more difficult.

  • Eating. Do not eat within 8 hours of surgery and do not drink within 6 hours of surgery. It is OK to take medications with a sip of water. Please discuss allmedications with your doctor and the anesthesiologist.

  • Washing. It is a good idea to wash the surgical area thoroughly the night before and the morning of surgery. Do not forget to wash inside your ears just like your mother told you. Please wash your hair the morning of surgery, comb it straight back, and hold it in place. Do not apply any make up

  • Arrival. It is best to arrive on time so things go smoothly. Please be sure to have someone else drive you. The surgery can not take place unless someone is there to drive you home before the procedure starts.

  • State of mind. Remember, this should be a happy and exciting time. A certain amount of nervousness is normal but you should not be overly concerned.

Anesthesia

The anesthesiologist will discuss with you what type of anesthesia is best for you prior to the procedure. He/she will take into consideration your medical history, the procedure, and your personal wishes.

The anesthesiologist will discuss with you what type of anesthesia is best for you prior to the procedure. He/she will take into consideration your medical history, the procedure, and your personal wishes.

The type of anesthesia is up to you. Most doctors prefer a general anesthesia and so do most patients, but local anesthesia with sedation is possible.

After the procedure

The procedure itself will take about 2 to 3 hours.

Immediately. Right after the operation you will be watched for 1 or 2 hours and encouraged to walk. Of course, there will be swelling and bruising but there is surprisingly little pain. You will have a head dressing on as well as ice packs to help keep the swelling down. When you lay down you must keep your head elevated usually on 3 pillows to prevent swelling.

That evening. It is recommended that you take it easy. You can walk around, eat, but not too much more. You must sit and lay with your head up on at least 3 pillows. You will have a lightly compressive dressing around your neck. This should be worn continuously for 1 week and then at night for 6 weeks. This will help keep the swelling down as well with helping the skin contract up against the underlying muscle. You should take as much pain medication as necessary and try to go to sleep early. Apply ice packs every 2 hours for the first 24 hours. You will be given medication to help keep the swelling down as well as to prevent infection.

First 48 hours. You will be walking around easily. You should take a shower the day after and gently wash your hair. Use a lot of shampoo so that your hair lathers easily and then apply a generous amount of conditioner. Just be gentle. The incisions will continue to ooze for about 4 days. You will see your plastic surgeon in the office approximately a week after the procedure to make sure everything is healing well. For one week you should wear the lightly compressive head wrap at all times except, or course, when you shower.

First week. One week after the operation you will have your first post-operative visit. The majority of the bruising and swelling will be gone by this time but complete resolution of swelling takes 3-6 months. Finish the antibiotics prescribed. Begin wearing your compression wrap just at night and do so until 6 weeks after the operation. Begin applying SCARGUARD to the incisions twice a day. This can be ordered on the internet. SCARGUARD is a combination of steroid, vitamin E, and silicone. It does a great job of decreasing redness and scarring. Continue to apply until the redness is gone.

Beyond. Swelling will not completely resolve for about 6 months but, as mentioned above, the majority of it will be gone by 1 week. Skin contraction will not start until about 4 weeks after the procedure and will continue to contract until about 6 months. The final result will not be evident until 6 months when all the swelling has resolved and skin contraction is complete but you will certainly notice a significant improvement right away.

Recovery time

The swelling and bruising will resolve in about 1-2 weeks. It is not unusual for people who work at home to start working 1 or 2 days after surgery. People with sedentary jobs go back to work after 5 days. If your job, however, requires strenuous activity then it may take as long as 3 to 4 weeks to return to work. Most people return to work in about 1-2 weeks.

Consultation

We have outlined below what you can expect from your neck lift consultation. Read carefully, as there are many suggestions that will save you time, clear up questions, and help you convey to your plastic surgeon what you want to accomplish.

Health History

All cosmetic surgery consultations begin with a thorough health history.This is especially true if general anesthesia is being used, but also applies to local anesthesia. Breast augmentations are usually done under general anesthesia. Rarely, if the implant is placed above the muscle, local anesthesia can be utilized. Prior to meeting with your plastic surgeon you will be given a health history questionnaire to fill out in the waiting area. There are five areas of your health you will be asked about. Be sure to answer it with detail so that your surgery and anesthesia can be optimized for you.

General Health

General health problems are important to discuss so that your surgery is as safe as possible. Be sure to mention any chronic illness. Of particular concern are: high blood pressure, diabetes, heart problems, liver and kidney disease, stroke, cancer, bleeding problems, and wound healing problems.

What will the plastic surgeon do if I have medical problems?

In short, he/she will make sure your health is optimized as much as possible to ensure your safety. This may mean referring you to your private physician.

If you have a health problem or are over 50 years of age you can often save yourself time by getting a letter from your private physician prior to your cosmetic consultation stating what the health problem is, how it is being treated, and whether or not you are able to tolerate general anesthesia safely.

If you are seeing any specialist (cardiologist, kidney doctor, psychiatrist, etc. ) be sure to bring a letter from them stating that you are able to tolerate surgery.

If you are not able to tolerate general anesthesia it may be possible for your breast augmentation to be done under local anesthesia if the implant is placed above the muscle. This must be discussed with your plastic surgeon.

Be sure to let your plastic surgeon know if you have ever had a blood clot.

Past Surgical History

On your questionnaire you will be asked about previous surgeries. Be sure to identify any problems you may have had with anesthesia. Of particular concern are previous cosmetic surgeries especially if you do not like the result and are interested in revision. With breast augmentation it is especially important to mention all breast surgeries including breast biopsies.

Allergies to Medications

Information about medications that cause allergies is very important so that these medications can be avoided. Of particular importance is the reaction you had, especially if you had trouble breathing. Be sure to include this information! Nausea is not an allergy but it is important to mention as well.

Smoking, Drinking and Drug Use

These three will certainly affect your surgery and MUST be mentioned so that your surgery can be optimized. Smoking causes a profound decrease in wound healing and will lead to worse scarring and a less favorable result. With large procedures such as a face lift, neck lift, tummy tuck, and breast lift smoking must be stopped at least 2-3 weeks before and after surgery. Otherwise, the results could be disastrous leading to non-healing wounds, poor scarring, and/or infection. With smaller procedures such as eyelid surgery, nose surgery, breast augmentation, and liposuction smoking will hurt the overall result but this may or may not be noticeable. In this case smoking cessation is strongly advised but is not mandatory.

Neck lifting involves elevating the neck skin. This puts a strain on the blood supply to the skin. Normally, this is not a problem but it may be in smokers. Smoking significantly decreases blood supply to the skin and can cause skin slough. The last thing you want after going through a neck lift is a large scar from poor healing caused by smoking.

What Do You Want To Change?

It is important that you have a clear idea of what you want changed when you go for consultation. The least favorite thing a plastic surgeon wants to hear is: What do you think I need done?

Look in a mirror and identify what bothers you. Be specific. It is helpful to break up the neck region into three parts.
  • Chin
  • Neck
  • Jaw
Evaluate each one of these areas individually as this is what the plastic surgeon does in during the exam.

Common complaints


  • Chin: Too small, too droopy (witch's chin).
  • Neck: Loose skin, too much fat, neck platysmal bands (turkey neck).
  • Jaw: Jowling.
Example of Dr. Cruise's neck suspension technique. Notice how the entire face is affected by the neck lift even though nothing was done to the face. Notice the square, boxy look of the jaw in the before. Compare this to the youthful triangular look in the after. Click to enlarge.
Example of Dr. Cruise's neck suspension technique. Notice how the entire face is affected by the neck lift even though nothing was done to the face. Notice the square, boxy look of the jaw in the before. Compare this to the youthful triangular look in the after. Click to enlarge.

  • Chin
    • Gives triangular shape to face.

    • Projects as far forward as the lower lip in women and slightly farther in men.

    • The undersurface is flat, not droopy.

  • Neck
    • Forms close to a 90 degree angle with chin.

    • No banding of the platysmal muscle (turkey neck).

Example of Dr. Cruise's neck suspension technique. Notice the dramatic improvement of both neck angle and jaw line. Click to enlarge.

  • Jaw
    • Should be visible without jowling.

Physical Exam

The key to the neck physical exam is to determine exactly what is causing the problem. Below is a typical sequence that an experienced plastic surgeon uses to evaluate the neck and what can be done to correct problems.

Chin

The importance of the chin in relation to the neck has already been outlined. See the section on chin augmentation for more information. With aging, some people develop a droopy chin otherwise know as witch's chin. This can be corrected or markedly improved during neck lifting. There are several ways to address the problem but they all involve removing the hanging fibro/fatty tissue that hangs below the ideal chin level. This can be done through a small incision just below the chin. Notice in the above Before and After pictures the improvement of the droopy chin. The addition of a chin implant greatly helps improve droopiness. Usually, as is the case above, this is not necessary. Fat removal in combination with a properly performed neck lift will obtain the desired improvement.

Neck

Hanging skin below the neck is probably the most common complaint. During your consultation, your plastic surgeon will palpate the tissue to determine if the cause is excess skin, fat, or muscle. Most commonly, it is a combination of all 3, therefore, all 3 must be addressed.

1. Muscle

This muscle is called the platysma and extends from above the jaw line to the clavicle. It is responsible for skin tightening. Men flex this muscle to tighten their skin when they shave. This is the deepest layer, therefore, during a neck lift it must be addressed first. With aging, this muscle becomes lax and separates into bands under the chin. These bands are excised through a small incision just under the chin. They are sutured together in the midline to create a smooth, continuous neckline. If necessary, the muscle is then tightened laterally through an incision behind the ears. Alternatively, the platysma muscle can be suspended into proper position by a suture that extends from one ear to the other.



Tight platysma causes jaw line to be well defined and neck angle to be sharp.

Facial fat cause jowling and a poorly defined jaw line. In addition, neck bands form causing the typical turkey neck appearance.


2. Fat
Excess fat under your chin can be palpated by pinching it between your thumb and index finger. This fat can be removed either by excision or liposuction. Fat excision is performed through the same incision under the chin that platysmal tightening is accomplished.

3. Skin
Loose, hanging skin is tightening laterally through an incision behind the ears. The excess skin is removed. The length of incision behind the ear depends on how much redundant skin is present. With minimal or moderate amounts, the excision may be completely hidden behind the ear. With a large amount of skin excess, the incision may extend posteriorly into the hair-bearing scalp. See picture of typical incisions below.

Jaw line
Jowls are fat deposits that have sunk below the jaw line. In youth, this fat was positioned up in the cheek where it belongs. With age, like all facial fat, it descends. It hides the jaw line and gives an unattractive square shape to the jaw instead of a more attractive triangular shape. It is best addressed by elevating it back into its cheek position via a face lift. Significant improvement, however, can be accomplished with liposuction performed at the same time as a neck lift.

Typical Neck Lift Incisions

Incision is positioned within the crease behind the ear making it unnoticeable even when the hair is styled back. A second small incision is placed in the crease below the chin. It too becomes almost unnoticeable with time.