The shape of the neck has a major influence on one’s appearance, even though technically it is not part of the face. But because the neck serves as the transition point between the jawline and the shoulders, it is just as easily seen as the rest of the face. The neck shape, particularly its angularity, influences heavily the shape of the lower face particularly the jawline. A smooth-skinned neck with a well-defined angle is associated with a youthful appearance. Conversely a loose and saggy neck is synonymous with aging, the more sag the older one is perceived.
When looking at improving the neck, it is important to understand its anatomy for all of its constituent parts can be modified. The soft tissues of the neck include the skin, the fat layer both above and below the plastyma muscle and the platysmal muscle layer deep. The hard tissues of the neck are the superior jawline (composed of the chin back to the jaw angles) and the inferior thyroid cartilage in the midline and the horizontal clavicles bilaterally. The hard tissues of the neck create most of its prominent borders with the soft tissue draped between them. The neck can be thought of as three aesthetic triangles, a central inverted triangle straddled by an upright triangle on each side.
Most of neck recontouring efforts are geared towards creating a better and more defined cervicomental angle. A smoother and more defined jawline above is another goal as well as any lower neck prominences reduced. Most of this is achieved by some form of fat removal and skin tightening/excision.
Liposuction Fuller necks in young patients can be treated by liposuction-assisted fat extraction. Liposuction relies on the principle of skin shrinking/tightening so younger patients with good skin elasticity are the best candidates. I prefer neck liposuction using a laser-assisted method, such as a Smartlipo probe. The generation of heat can only help the skin tightening process. While usually not an ideal procedure in older patients alone, I have been surprised in a few older patients (> 60 years old) who refused any additional procedures how much improvement they got. (although the result was not ideal)
Submentoplasty When the fat in the neck is not just above the plastysma and the neck angle is very obtuse, the next step up from neck liposuction is the submentoplasty procedure. This is a neck reshaping operation in which fat is liposuctioned through the neck but also removes fat under the muscle in the midline and tightens the muscle as well. This is done through a small incision under the chin and is also known as a submental tuckup. It is used for younger to middle-aged patients with a minimal amount of loose skin but too much fat. It is also used as a revisional procedure after a facelift when there has been some rebound relaxation of central neck tissues or residual skin remains right under the chin.
Facelift/Necklift Facelifts are easily misinterpreted as a procedure that affects more than the neck and jowls…but it does not. They are better described as necklifts or lower facelifts. While there are many different variations and techniques used for facelifts, and a lot of marketing that adds to the confusion, at its most simplistic level there are only two basic types… limited and full facelifts. Both approaches use incisions around the ear but the length and location of the incisions and how much change occurs in the neck or jowls. Limited facelifts with their shorter incisions around the ears mainly improves sagging jowls and has a bit of effect on the neck through a hammock effect. The neck can be more dramatically improved with this operation if it is combined with liposuction. It is best used in patients whose primary complaints are about their droopy jowls and not their necks. Full facelifts are used when the neck is the main problem, often even worse than the saggy jowls. With a longer incision that goes behind the ears, it has a powerful effect on changing the neck. It almost always incorporates liposuction of neck fat and tightening of the platysma neck muscles as well with the additional use of an incision under the chin. Most patients over the age of 55 years old need a full facelift.
Direct Necklift The most uncommon form of soft tissue neck reshaping is the direct necklift. While it is the most powerful and simplist method of a necklift, it is infrequently done because of the location of the scar. Rather than around the ears, the incision to do a direct necklift is right down the center of the neck. Loose neck skin and fat is directly cut out from the chin down to the thyroid cartilage. The platysma muscle is sewn tightly together as well. Closure of the neck cutout creates a vertical or zigzag incision. While this scar is objectionable to younger patients and most women, it can be the preferred approach for older men with large hanging neck wattles and who don’t want to undergo a ‘facelift’. Interestingly the beard skin of the neck heals remarkably well and has much less scarring than one would anticipate.
Dr. Barry Eppley