David A. Newman, MD, FACS

Because you are healthy. It’s normal to have skin folds which result from stretchy skin that has a normal amount of fat underneath. 

It looks like when the patient bends his head to the sides there is excess aft tissue (skin and fat) but in the other neutral position poses there is no excess. Any further treatment may lead to being able to see that surgery or something has been “done” and with no improvement. So I therefore dont recommend any kind of treatment. 

I think it’s important to understand why the skin is becoming loose and that will guide treatment. And it’s also important to assess the severity of the laxity, which is of course to say that it is mild. 

There is a loss of elastic fibers as we age and this works directly on skin to cause it to elongate and stretch which leads to hanging skin. At that same time, the ligamentous attachments keeping the skin adherent to underlying structures are also weakening. But also our own muscle forces are working on the skin to aggravate these aging effects. 

The platysma muscle is a flat sheet on both sides of the neck and right under and attached to the skin. It’s effects in the skin can be seen if we pull the corners of our mouth down towards the neck. During normal everyday facial movements and with eating motions, the platysma joins with the other facial muscles to move skin and do as to convey emotions and help with swallowing. Because ofthis motion, the platysma can lead to stretching of neck skin and accelerate the aging process. 

The other thing that can happen with the platysma is that it shortens with time and because it is tighter, it can pop out from the neck and lead to vertical banding, where the inner edges of the muscle can be seen to look like a bow string and thus the neck loses its smoothness. This banding effect can occur earlier in life than the actual skin laxity. And since platysmal aging is partly driving the effects of skin aging, platysmal surgery may help prevent or at least slow down the aging effect on skin. 

Since the skin laxity is mild, a neck lift with adequate repair of the platysma and redraping of the skin would be a very good alternative. As the patient ages, she might notice joeeling and only require a minifacelift as the neck has already been treated. 

Thank you for your question. 

This patient has brought up some interesting observations and questions which beg a good and satisfactory explanation. First off, I think its important to differentiate between widely spaced nipples and the distance between the inner edges of the breast, most often referred to as cleavage. And its important to do so because in thinking and talking about treatment, we should identify which things we can and which things we cannot and would rather not attempt to improve. 

Remember that cleavage can be improved by placing an implant that will be large enough so that the base of the breast comes closer to the midline. That has nothing to do with the nipples, as long as the midpoint of the implant is directly under the nipple. So from this, we can infer that the larger the implant, the better (or closer) the cleavage. SSo then, what size will give the best cleavage? Surgeons have their different ways to achieve this. I rather would like the patient to give me some wiggle room, allowing me to choose the volume of implant necessary to get cleavage. I discuss this with the patient at their consultation and at other meetings prior to surgery but then ask the patient to allow me to pick the size that will bring the volume out to the edge they desire. This, takes away from the patient's thinking mostly about the size and not really connecting with the fact that we are using volume to create shape, and you can clearly see what I mean by that when talking about cleavage. How does the patient know what exact volume will create the cleavage they wish?  I have done thousands of augmentations and I dont even know exactly. I can give an educated guess, perhaps plus or minus 30 cc. But I would rather not guess because there a many factors that can affect the volume, like skin and muscle strechablilty. So I actually measure the volume required to get out to that edge, in this case the cleavage area and then I pick the implant that can is that volume. 

Patients feel more in control when they choose the size, and I also think its very important for the patient to express their wishes, and I would try to achieve their goal, in terms of size. But I think that patients more often express their size wishes but dont really make a connection that there is a range of sizes that can give them the best shape, and that can often be best determined during the procedure, which is why I ask for some wiggle room, perhaps a quarter to a half of a cup size to get the best shape I can get given their anatomy. So lets see both the forest and the trees when talking about breast augmentation and not only talk about the size, but also about what the size does to the patient's shape. Remember, patients have different goals, that you have your specific goals which may be entirely different from other patients goals. So lets talk about everything and not just one thing.

The other issue the patient brings up is the issue of nipple placement. The nipple is described generally as sitting in the midclavicular line, a line drawn from the middle of the collarbone straight down. It looks from the pictures that the nipple sits just outside that imaginary line. So an implant would not move the nipple itself as it will stay anchored to the breast. Making the pocket extend farther to the side might give the illusion that the nipples
are less widely placed but I think will help in another way, in that the nipples are not only slightly wider placed (and I would like to say not that bad really), but that they are divergent, or point outwards. Extending the pocket for the implant laterally, towards the side might improve this slightly, making them more convergent and this will also disguise the wideness between the nipples. 

I have a rule I tell patients which makes them laugh, which is, "the nipples go where the breast goes." The cause of divergence, I think is a little more complicated than just nipple placement and involves how the breast is situated on the chest wall. The rib cage in different patients has differing angulations and you can see in the photosthat the chest bones themself arent flat from side to side but as you move to either side the chest wall itself falls backward. This is totally normal and everyone has some angulation to their chest wall and I see this as part of the natural beauty of the human form, that there are variations in our anatomy. Wouldnt it be boring if everyone were built the same? In fact, you can see that the breasts which are sitting on the chest are also diverging, pointing outwards and an overwhelming majority of women have some degree of divergence which, as I've mentioned has it own intrinsic beauty. 

I would just like to finish by saying that we are talking about some very specific issues and taking these ideas apart but I think its very important to keep our eye on the ball and to see the big picture which is that breast augmentation has a very high degree of patient satisfaction and that not only can the size be more what the patient wishes but that the shape can be greatly improved. So, in this situation, if more cleavage can be created, more fullness and a better shape and the size near to what the patient wishes, having some divergence is a small thing as compared to the huge improvement gained. I guess I am saying not to get hung up on one thing and see the big picture. I think patients can appreciate and love their cosmetic result in that fashion.

The type of facelift procedure can have an effect on its longevity. But I would rather say that the extensiveness, the completeness and the time spent in performance of a facelift is even more important.

It would then be easy to simply ask the surgeon how long it will take them to perform your facelift, but things are slightly more complicated than that. There are other factors that can make surgery time longer or shorter including the type of facelift, what pace the surgeon moves at, and the type of patients, especially young or older that the doctor sees in his or her practice.

I think that the best way to know if the proposed surgery is complete and thorough is to ask the surgeon at consultation how the procedure is performed, and how the different maneuvers will improve the different areas of the face. In this fashion, one can compare different surgeons and their techniques and make some correlation with their before and after photographs.

Clearly, spending four hours in the performance of a facelift is going to give alot more long lasting improvement than a ninty minute procedure. When a patient requests consultation with me regarding performance of a facelift, I can best inform the patient by drawing the patient's face and showing exactly how I do the surgery. You might be quite surprised to hear that most patients actually love a description in a drawing and I think that the drawing really helps the patient to understand how things can be moved in a natural way, with no tip-offs that a facelift has been performed. 

Well performed facelifts a very long-lasting and are the gold standard to which all surgical and nonsurgical facial procedure are compared, because they are so complete and successful. I think it is also very interesting that the different areas of the face undergo different amounts of relapse over time. For example, the neck tightening, if done well and completely can last up to thirty years in some patients, depending on their skin type, genetics, other life changes, etc. but that the joweling tends to recur more quickly.