Hi Heidi,A direct necklift is essentially excising the loose skin directly down the front of the neck and sewing the edges together. To prevent a scar contracture or "web" right at the chin to neck angle (cervicomental angle) usually a Z-plasty or zig-zag scar is performed to prevent the scar from forming across the neck to chin angle. The extended scar forces the incision to be horizontal at the chin to neck angle to prevent this webbing or skin contracture scar. I am not philosophically opposed to direct necklifts and I have performed them in the past. However, I don't like direct necklifts if it extends down the front of the neck so that people who are standing in front of you can see it. I occasionally perform a direct necklift if there is loose skin directly under the chin and the patient does not want to have a lower facelift to "walk out" the extra skin under the chin around the jawline and up the sides of the face.In your particular case, you have had 2 prior facelifts, and it does not appear that the surgeon performed a necklift with your prior facelifts. My definition of necklift is when the surgeon makes a small incision under the chin to tighten the muscles in the front of the neck (the platysma muscles) in a procedure called the platysmaplasty. Simply making incisions around the ears in a mini-facelift type fashion and pulling the skin upwards and around the ears will likely result in the neck falling and potentially pulling the earlobes down with it (called a pixie ear.) A pixie ear can pull the earlobe down and elongate it as well as rotate the ear so the back edge lines up with the jawline. Patients who have had prior facelifts are more prone to pixie ears.Another risk with another facelift incision is that the hair around your side burns/temples cannot be raised any higher. If anything, the surgeon may release some of the temple hair tuft and advance the hair downwards to further reduce any tell-tale signs of a facelift.Perhaps your surgeon may be worried making things worse with the prior two facelifts (hairline, incisions, earlobes) and is pointing you towards a direct necklift which will avoid those things. Another possibility is that when the surgeon is simulating a facelift, he or she is noticing tension lines on the cheeks or the windswept look where there are horizontal tension lines along the lower cheeks. This may be another reason for avoiding a third facelift.In revision facelifts, I check to make sure that platysmaplasty was performed properly (if at all), then the extra skin is simply pushed upwards to make the skin under the chin as snug as possible (without making the vertical incision) and the excess skin pushed backwards behind the ears to make the skin as snug as possible over the front of the neck (the throat/windpipe area).Any limitation of the incision around the ear, is risky. The skin removal under the chin will mainly be located under the sideburn. Limiting the incision to the front of the ear without making an attempt at a horizontal incision following the existing curilinear scar under the sideburn will not allow for enough skin removal under the chin. Some surgeons will limit the incision to the front of the ear and not extend it forward or horizontally to either not disrupt the hairline or to keep the incision shorter. The problem with making the incision too short is that all of the skin removal ends up being under the earlobe, which increases many risks. In revisions face and necklifts, I rarely excise much skin if any right at the earlobes, or in front of the ear, other than to remove the old scar. However, I try to keep as much skin as possible.around the base of the ear, or the U-shaped incision around the front and back of the ear. The question patients then ask me is where to you remove the skin? The main skin removal is under the sideburn and in the incision along the edge of the back hairline. This allows the surgeon to excise as much skin as needed or the patient's anatomy will allow without removing any hairbearing skin, which would further raise the hairline. If I were to use an analogy, if the skin removal were like an upside down pair of pants, that I was holding and the waist of the pants were touching the floor, how would I want to lift up the pants so that the waist of the pants were 3 inches off of the floor. The incision under the sideburn and back hairline is the hem on the bottom of the pants. I would cut 3 inches off both the legs of the pants and that would lift the waist of the pants 3 inches away from the floot. If I left the pant legs the same length and cut off 3 inches around the crotch area, and pulled up the pants 3 inches that way, all of the pressure of the lifting would be right at the crotch with the pant legs not being any shorter and helping to support the lift. Since another 3 inches is now cut off of the crotch of the pants, the location of the crotch of the pants is the location of the bottom of the earlobe. The first question is how secure is the shortening of the pants at the crotch location? If the neck falls, what will happen to the earlobe? Will the earlobe get pulled down even further.For these multiple reasons, performing a 3rd face and necklift on you would be risky, unless the surgeon has certain precautions in mind regarding making the overall result worse, both during the consultation (whether or not to recommend it at all) and even more importantly during the actual surgery it is recommended.If the facelift portion is limited due to tension lines on the lower cheeks, then less skin will be able to be removed using the incisions around the ears. This may leave a smaller amount of excess skin under the chin. The profile improvement has been achieved, but the skin under the chin is not snug enough. In these cases, I have performed a limited direct necklift only under the chin, but not extending down the front of the neck just to get it snugger under the chin, but at the same time avoiding the wind-swept look/horizontal tension lines. This incision usually heals well, but I will try my best during the revision facelift and necklift to make it as snug as possible to possibly avoid the additional skin removal under the chin.Good question, but the answers are not easy.Good luck on your Necklift journey.Best,Dr. YangP.S. There is a new feature on Realself, which is the "Follow" button. It is similar to the "Like" button on Facebook. If you like my response or any of the doctor responses while you research on Realself, you should "Follow" them. You will get email updates, when the doctors you follow post any new answers to questions, post new photos, or have any new reviews.
