Neck Lift Procedure Options

I see a large number of patients who are interested in improving poor neck definition and/or loose neck skin only, but who do not want or need a full facelift. Many of these patients are in their 30s and 40s and find that their neck is their only major facial aging issue. However, I will also perform a necklift only for many patients in their 50s and 60s who do not want to change their upper facial appearance and who feel that it is primarily their neck makes them look older or ‘matronly’.
These patients are particularly bothered by the appearance of their neck in profile, where the ideal sharp transition between jawline and neck has gradually faded and in some cases has completely disappeared. Even in the absence of other signs of facial aging, a poorly-defined or sagging neck can add years to a patients overall facial appearance. When performed expertly and with great attention to detail, a necklift surgery can dramatically restore a natural and youthful neck profile, with no outward evidence that surgery has been performed. The adjective that immediately comes to mind when I review ‘before and after’ images of my necklift patients is elegant – for restoring a youthful neck contour truly makes the patient appear not just younger but also refined and elegant.
Necklift surgery can consist of a variety of surgical techniques that are carefully selected to meet each individual patient’s particular needs. It is therefore important to select a qualified physician with a great deal of experience in numerous necklift procedures. In younger patients with good skin tone, submandibular liposuction alone may produce a dramatic improvement. For some patients with good skin tone but poor definition at the angle of the neck, I add a suture-suspension necklift to sharpen the angle between the jawline and neck. This procedure is minimally invasive, produces no easily visible incisions, and has a very quick recovery. It will not, however, improve the situation if a true excess of skin is present.
Patients with more advanced aging changes in the neck generally require tightening of their neck skin as well. The neck is the one area in facial rejuvenation where a tighter and more toned surgical result looks natural and aesthetically ideal (as opposed to the face where ‘tight’ and ‘tighter’ just looks like surgery). Neck skin removal is accomplished through incisions around the ears which can be extended a short distance into the scalp if necessary. If the incisions are created and closed correctly and without undue tension, a very natural looking result can be obtained with no obvious signs that a necklift has been performed. A great deal of experience and expertise is required to avoid distortion of the ear and surrounding skin.
Producing a level and youthful contour below the jawline often requires treatment of the soft tissues that are deep to the subcutaneous fat layer. Through a small, hidden incision below the chin the subcutaneous fat layer is thinned, delineating the anatomy of the platysma muscles which form the two parallel anterior neck ‘bands’ in many patients as early as their forties. The anterior borders of the platysma muscle can be sutured together in the midline of the neck, permanently eliminating the platysma bands and creating a sling effect which lifts and supports the neck soft tissues. This procedure is called a ‘platysmaplasty’. In some patients a prominent fat pad exists deep to the medial border of the platysma muscles which cannot be reduced by liposuction, and if necessary it is directly reduced prior to platysmaplasty to further improve the submandibular contour.
As the jawline and neck are immediately adjacent, patients with jawline aging issues such as jowls can have those issues addressed at the same time as a necklift. The skin of the jawline can be elevated in continuity with the neck skin to restore a smooth jawline contour. For many patients I combine this with structural fat grafting of hollow areas and conservative liposuction of excessively full areas to produce a jawline contour that is as smooth and youthful as possible.
Buyer beware: a number of ‘limited incision’ and ‘quick recovery’ facelift procedures are currently marketed to patients with names like “The Quicklift”, “The Lifestyle Lift”, “The Weekend Facelift”, “The S Lift”, “The MACS Lift”, etc. As with most things in life, if it sounds too good to be true, it usually is. In my opinion, the results of surgery are in direct proportion to the time and effort that the surgeon has put into the procedure. Most of the procedures I have listed above cut corners to arrive at a shorter surgical time and quicker recovery (which, by the way, isn’t always the case), and most of them undertreat or do not at all improve the neck. Additionally, ‘cutting corners’ in the neck almost always leads to distortion of the neck area skin, which often is quite readily apparent in ‘before and after’ images of these procedures with gimmicky names. Look for abnormal and unnatural-appearing skin tension lines in the lateral neck as well as below and behind the ears.

It sounds like your facelift did not adequately address the platysma. The platysma is the muscle that creates the neck contour. As you age, the muscle splits into two parts, one on either side of the midline. The free edge of the muscle sags and causes the turkey gobbler that makes you look old.

Many people think that the cause of the turkey gobblers is excess skin. This is only partly true. Excess skin can make a neck look old but typically an early recurrence of the neck folds after a facelift is the result of inadequate tightening of the platysma.

If what I am saying sounds correct, then what you need after last years surgery is a simple platysmaplasty, which requires a 1 inch incision under the chin - not the vertical scar that you describe in your question.

Good luck!

Robert M. Freund, MD

This is a very good question and brings up a number of very good points.

The two general types of procedures that would be discussed with you in my practice are a "Minimal Incision Necklift" and a Facelift; I will explain the difference. Direct removal of skin via a Z plasty is also possible but generally only applies to a small sub-category of patients willing to have a mid-line scar.

A "Minimal Incision Necklift" involves an incision just under your chin, below the chin crease, roughly 2.5 cm in length (this will vary according to the patient) and a 1.5 cm incision behind each ear. The general concept is to judiciously remove fat excess, stitch together the platysma muscle ( a paired, thin, long sheet of muscle visualized when you strain your neck) and place an interlocking suspension suture from side to side to help to maintain the contour of the neck. No skin is removed, because generally more skin is required to fill a concavity than to maintain a convexity. This axiom holds true up to a certain limit. I would agree that wth other posters on this topic that most patients in their late 50's are getting to to the point where the degree of excess skin cannot be addressed by this technique and skin removal becomes necessary.

For patients with this certain degree of skin excess, a traditional facelift is generally the best approach because it allows for removal of excess fat, a platysmoplasty/ muscle resuspension, and removal of skin excess via concealed incisions. Any good facelift surgeon should be able to make the incisions look inconspicuous by following a number of time honored surgical principles. As I tell my patients: If your incisions don't look good, I don't look good, and I do not want to have that happen. A responsible, ethical surgeon who takes pride in his work has a vested ineterest in an excellent outcome for his/her patients.

From what you describe, the right operation was done on you. The direct excision of skin in the neck is almost never done except in older men as it can leave an obvious scar that looks unsightly and is permanent.

Sometimes a patient expects more than the procedure can deliver. This should have been addressed before your surgery, but you should still discuss this with your surgeon.

Sometimes, the elastic nature of a patient's skin has been badly damaged by the sun and this can compromise the longevity of your result.

It may be that your result is "as good as it gets" for your face but it may also be that more could be done to get to the result you want. You might even need to visit with another surgeon in your area to review the result and your options.

It sounds as if you underwent a facelift. For whatever reason, you were unhappy with your results.

There are several possible explanations, many elucidated by my excellent colleagues below (expectations too high, sun damaged skin loses its elasticity, possible additional laxity). You should definitely mention to your doctor your dissatisfaction and see if there is any additional tightening that is reasonable to do without causing distortion to anatomic structures.

You might also want to consider if there are areas of hollowness such as around the mouth (nasolabial folds, marionette lines, lips, cheeks, cheekbones, undereye areas) that could benefit from augmentation with your own tissue, especially if you have had previous eyelid surgery. In our practice we use Livefill (autologous tissue; fascial fat grafts).

If tightening has been done on the side of the face but not in the center (midface), a cheeklift may be an option, especially if you had had previous lower eyelid surgery in the past.

It is also possible that the sun damaged areas could be resurfaced with a conservative CO2 laser resurfacing, both to reduce surface actinic changes from the sun, as well as to give additional tightening.

We have found that results with radiofrequency tightening devices (Refirme, Thermage) for this problem were temporary and disappointing. The internal laser offers nothing in my opinion to improve the results from most patients with your issue that should not have already have been done during your primary surgery.

I hope this helps, and good luck!

Hello Imogene,

Based on your description of things it sounds as though you would benefit from a neck lift or platysmaplasty.

I am assuming that the results from your faclift are still satisfying to you since it has only been a year. That means your jaw line is smooth and your lower third of the face has a more youthful appearance.

Think about your anterior neck as the area over your throat and under your chin. This area is covered by the platysma muscle. If you can see muscle bands on your neck then this means that the platysma muscle is not connected in the middle and the bands you are seeing are the edges of the muscle. During a platysmaplasty excess fat is removed and the muscles are sewn togther in the middle (this is done much like the way an old fashioned corsett is tightened). Some extra skin is removed but unless the skin is very weak and "crinkly" then not much skin removal is needed. If the skin is weak and "crinkly" then addtional incisions can be made behind the ear to pull up, remove and tighten the skin.

The incision for the platysmaplasty can be kept quite small (1.5-2cm) and can be easily hidden in natural creases (these creases run parallel to your chin and do not need to go down the throat area).

A neck lift or platysmaplasty can be readily performed with local anesthesia and offers long lasting and satisfying results.

It is also important to address the quality of your skin with non-surgical approaches to get yourself the best results.

                  Your history suggests the development of recurrent skin sag with neck wrinkling following facelift surgery. This situation can occur for a variety of reasons including continued facial aging or inadequate treatment of the original problem. Since this issue has occurred within a year of the original procedure, failure to address the anatomic structures of the mid neck is probably the most likely explanation.

                  Under these circumstances it’s difficult to make a recommendation without pictures or a physical examination. The treatment of this condition depends on the cause and severity of the anatomic deformity.

                  In the majority of cases, this type of deformity can be treated with a neck lift through a small one inch transverse chin incision. Through this approach the underlying platysma muscles can be repaired and the central neck recontoured. In severe cases the facelift may need to be repeated with simultaneous repair of the midline neck muscles.

                  When this situation occurs consultation with a board certified plastic surgeon is appropriate. This surgeon should be able to make an appropriate recommendation. 

Necklifts can be performed as a stand alone procedure, or as part of a traditional facelift. In many cases, a patient may not want or need a full facelift, but it depends on the unique issues and goals of the patient. In simple terms, with the first option, often excess fat is removed, and the platysma muscle is stitched together in such a way as to keep the proper contour. This is usually done when there is minor sagging in the middle of the chin.

With a traditional facelift however, not only are the above procedures performed but also excess skin is removed if necessary. This is more often done when there is sagging along the sides rather than the middle of the chin.

Most procedures that truly rejuvenate the neck are surgical in nature. Nonsurgical procedures to improve the neck are usually limited to about a 10-20% improvement at best. Neck lifting can be done with a variety of incisions, around the ear or under the chin being two, and an experienced necklift surgeon can help determine which (either, or both) is the best option for you.

A Neck Lift is sculpting and restoring your neck's contour and tightness back to a youthful state. This requires addressing the multiple components involved (muscle, skin, fat, and the ligaments).

In youth, the neck skin sticks and clings to the deeper neck muscles and connective tissue layers tightly. As you age, these layers start to disconnect from each other and loosen, which causes the platysma muscle (the major sheet of muscle that covers your neck) to form "BANDS" in some areas. The cervical fascia (platysma muscle's connective blanket) of the neck needs to be tightened along with the muscle.

In addition, the excess fat over and under this muscle that bulges through and sags is reduced and sculpted.

The last thing that is done (ONLY IF NECESSARY) is a little bit of skin may need to be removed from behind the ear. This is not always necessary.

An important thing to remember is that depending on your age and the way your neck is, you may not need all of this. Sometimes a little liposuction (liposculpture) may be all that is needed. In general, when the angle line of the neck with the chin is not well defined, more than just liposuction is needed.

Also, liposuction is not a good procedure if the plastysma muscles has become weak (as discussed above). After an evaluation in the office, the best procedure for your specific anatomy will be recommended.

Lastly, more often than not, a neck lift is combined with a face lift or "facial shaping" procedure. As with the upper eyelid--eyebrows, lower eyelids--cheeks, the neck and face are intimately connected and to work on one and not the other may look imbalanced and weird.

Thanks for sharing. Current neck rejuvenation treatments:

1. Surgical Neck lift* with a lower facelift would be the gold standard and get you the best results
2. Surgical Neck lift* would be the next best procedure
3. Neck liposuction and or laser lipolysis if only fat removal is required, typically in a younger patient
4. Ultherapy is an FDA approved non invasive tightening using ultrasound technology
5. Kybella is a new FDA approved injection that melts fat under the chin

*It is important the a Neck lift involves some liposuction and importantly a platysmaplasty which is a procedure that tightens the underlying loose neck muscles.  

Talk to several board certified surgeons experienced in face and neck lifting.