Neck and Lower Facelift Are Too Tight?

Hi La in Watervliet,

I agree with the other surgeons and their reassurances.  My approach for pre- and post-operative counseling for these cosmetic procedures is to try to explain things in a way that patients can fully understand on their own.  This takes some of the fear out and I think gives the patient some feeling of control back.  In some cases of pre-operative counseling, fully understanding the procedure and the recovery leads to the potential patient not choosing to have the surgery at all.  I would rather that they decide that they don't want surgery before having spent a car's worth of money, instead of regretting it after surgery, because they didn't actually know what they were getting themselves into.  The scariest thing is to be in a car that is out of control, and you aren't the driver.  A good understanding of what is going on, puts you back in the driver's seat.  I hope my additional answer helps to reassure you.   

In general, patients who get a lateral platysmaplasty (the stitches behind the ears you were referring to) will usually have at least some kind of noose-like sensation pulling from ear to ear.  How long the sensation lasts depends on several factors depending on what surgical techniques the surgeon used, the types of sutures (permanent vs. dissolvable) and lastly how aggressive the surgeon was when tightening the deeper layers of tissue (SMAS/platysma.)

Why are you feeling the noose sensation?  Based on your description of your procedure, the submental platysmaplasty and the lateral platysmaplasty were both performed in order to give you the best possible neck profile.  The submental platysmaplasty is useful for creating the chin to neck angle that people associate with a youthful neck.  This involves tying together the separation between the two platysma muscles on the left and right side.  It is particularly useful when the patient has hanging neck muscle bands or platysmal bands.  As the submental platysmaplasty is performed in ties together the two sides similar to tying shoe laces or tightening a corset by pulling the left and right "leaf" together in the middle.  The sutures can be individual stitches or continuous similar to laces on a shoe, boot, or old-fashioned corset.

The tightness you feel directly on the Adam's apple area (AKA voice box or the medical term you can google, the thyroid cartilage) is pressure caused from the last stitch on the submental platysmaplasty which is located right at the chin to neck angle (AKA cervicomental angle.)  Since there is no longer a separation between the two platysma muscles in the middle, the combined platysma muscle from the platysmaplasty creates a sling under the chin, and the back edge of the sling is right against your Adam's apple area.

A submental platysmaplasty alone usually does not cause the noose-like sensation.  Instead, this usually causes a tight feeling under the length of the chin.  Now that you have the sling under the chin, the back edge of the platysma or the lateral edge of the platysma muscle which is located right below your earlobes is then located and lifted up towards the tough tissue behind the ears (called the mastoid fascia.)   This Mastoid fascia is devoid of fat and other structures, and is mainly tendon/ligament type tissue which is particularly good for placing suspension sutures since is it unlikely to rip through, unlike suturing fat, which can result in the thin fishing line-like suture to rip through the fat, like a wire through cheese.  

Auxilliary necklift techniques, which you may not have mentioned can also cause a noose-like sensation, and are actually similar to a noose.  There is a continuous permanent suture going from the back of one ear to the back of the other ear and sutured directly to the tough mastoid fascia.  This is called a Giampappa stitch after Dr. Giampappa.  Another technique usually reserved for a revision necklift or a really tough heavy neck, is when a strip of Gortex (yes, gortex like the waterproof raingear, but medical grade that can be implanted under the skin) usually 1/4" to 1/2" wide ribbon. is also sutured from the mastoid area and the ribbon is slid under the neck skin (without twisting the ribbon) over the chin to neck angle (cervicomental angle) where the Adam's apple is located, and back to the other mastoid fascia.   If this ribbon is pulled very tight, the patient will have a tight noose sensation, if it is left loose then the patient may not feel the noose sensation at all.  Usually it is somewhere in between, since the whole goal of the necklift is to lift and tighten the neck.  The patient is already willing to go through surgery for the improvement, so the best chance to give the patient the improvement they want and deserve is while tightening the lateral platysma/giampappa stitch/gortex sling.

Having said all of that, I don't tighten the lateral platysmaplasty very much.  I depend on the submental platysmaplasty to give 80% of the neck contour and slightly lift the lateral platysma for the remaining 20%.  Why?  In the beginning of my practice, I performed mainly lateral platysmaplasties for the neck, and was able to get a significant initial improvement on the neck profile only to have it fall 3-8 weeks later.  I was using permanent sutures at the time.  All of those patients were warned preoperatively of the noose-like sensation and was reassured pre-operatively and post-operatively that this would subside and it did.  The observation that I made was that when the noose-like sensation went away at various times for various patients, the neck would also loosen.  In fact for one particular patient, who was nearly 2 months out after her facelift, noted that she had turned her neck to one extreme and felt a ripping sensation behind one of her ears (the mastoid area.)  My interpretation of this was the permanent suture ripping through.  Her neck also fell and required a submental platysmaplasty as part of her revision procedure to get the result she wanted.

Soon after, I began performing submental platysmaplasties with most of my face and necklifts which required "heavy lifting" on the neck area, this resulted in much better and consistent neck contouring results.  Since my prior experience with only tightening the lateral platysmaplasty resulted in the sutures likely ripping through, I did not have much faith in them and only tightened this area enough to help smooth out the excess skin behind the ear and reduce tension on the skin in that area.

Since the really tight lateral platysmaplasty sutures won't hold up the neck long term (in my opinion), I didn't want to subject my patients to the noose-like feeling on the front of the neck, I kept this area "medium tight" enough to help give the neck area some tension like a trampoline, but not so much that it is reaching its ripping point.  The observation for these patients was that they did not feel much noose sensation if at all afterwards.  

In your case, the combination of the submental and lateral platysmaplasties is likely giving you this tightness, with additional post-operative swelling which will eventually go away.  Imagine wearing your ideal jeans, but having temporary swelling around the waist and hips.  Your jeans will feel uncomfortably tight, but the goal is to get you to look good in those ideal jeans an not necessarily worry about the initial discomfort when you are having normal post-operative swelling.  

If the tightness is still there after the swelling is gone, hopefully it is improved enough that you can leave it alone.  But if it is not, then you will need to wait for the permanent sutures to loosen up over the following months or if dissolvable sutures were used, it will also loosen in a similar fashion over the following months.  If it is still uncomfortable to the point where you want something done, then stretching exercises to try to loosen up the lateral platysmaplasty sutures or a small surgical procedure to "release" that area could potentially be performed, but it may affect your necklift result somewhat depending on how well the submental platysmaplasty was performed.

No matter how tight the surgeon wants to make the neck, it doesn't stay that tight.  The body, face and neck simply doesn't like it to be that tight, so it will find a way to loosen things up.  Even if too much skin is removed, and it will be tight when that happens, the body will stretch the scar and create a widened, atrophic scar which looks a bit like a stretch mark, to give the skin some "room to breathe." The widened scar looks bad, but our body/tissues aren't concerned about cosmetics, but simply don't like the tension (which in your case means your body likes to be comfortable.) Some patients expect the opposite of you situation and want to have that super-tight feeling so that they know the neck is being lifted.  Yet, we have to tell them that the tight feeling will go away, and no matter how tight we make it.  For these patients, it sounds like an excuse, but it is actually difficult for the surgeon to keep that tight feeling going permanently.  

Sorry about the length of the answer, but I like to explain things using analogies which lay people can understand and digest more easily than short answers.

Best,

Dr. Yang

Do not worry - things will loosen. I can think of one patient who came back one week post-op - furious - since she was so tight - and I suggested that she be patient - and she was - and ironically, six months later the very same patient asked that I in fact tighten her skin/face even more!That being said - the tightness likely comes from tightening the platysma muscle and also the SMAS - two strong supporting muscle/fascial layers below the skin.  This tightening is good - it will support and prolong your result - and will become less uncomfortable with time.Best of luck!

A sensation of tightness after a face and/or neck lifting procedure is very common and to be expected. Some of this feeling is due to actual tightness of the muscle and skin layers, and some of it is actually due to numbness and an awkward sensation in the treated areas. This sensation will improve dramatically with time and will start to feel normal again as the tissues heal. Any outward appearance cannot be judged at one week after surgery as it is simply much too early to judge the results. Results will continue to evolve over time. Of course, be sure to discuss any postoperative concerns with your surgeon.All the best,