Key points
- A well-defined neck contour is regarded as the foundation of facial rejuvenation surgery [1].
- Cosmetic problems after neck surgery often result from treating the structures of the neck too much or too little; it is explained that, with the platysma as the dividing line, shallower structures tend to be overtreated and deeper structures tend to be undertreated [2].
- Methods that extend the deep-plane approach down to the neck and lift the skin, SMAS, and platysma together as a single unit have been described, based on the authors' experience and anatomical evidence [3, 4, 5].
- It has been pointed out that new complications have appeared with the arrival of minimally invasive techniques, so an accurate assessment should come before choosing a method [2].
Neck aging and the platysma
The platysma is a thin, sheet-like muscle that lies just beneath the skin at the front of the neck, and it connects upward with the SMAS layer of the face. With age, the front edges of this muscle can loosen and show up as vertical bands on the neck, or the contour under the jaw can become less defined.
A review of neck lift surgery explained that a well-defined neck contour remains the foundation of facial rejuvenation, and it described the anatomy relevant to the neck lift in detail [1]. The neck is made up of overlapping layers of skin, fat, muscle, and deeper structures, so it is important to identify which layer the problem is in.
Common problems in neck surgery
A review of pitfalls in neck surgery explained that many cosmetic problems result from treating the components of the neck too much or too little [2]. With the platysma as the dividing line, the shallower structures are easy to reach and therefore prone to overtreatment, while the deeper structures are hard to reach and therefore prone to undertreatment and an overall imbalance [2].
The same review concluded that a strategy of accurately evaluating every structure of the neck and treating them in balance can prevent and correct these problems [2]. For example, if only the shallow fat is overtreated while problems in the deeper structures are missed, the neck contour can end up looking less natural.
Surgical methods that address the platysma
The vertical neck lift is an extension of the deep-plane facelift down to the neck, and it lifts the skin, SMAS, and platysma together as one unit [3]. The goal is to move the loose tissue of the neck vertically toward the face, rather than to the side or behind the ear; to do this, the flap is extended from the angle of the jaw down into the neck to release the supporting ligaments of the neck that keep the platysma from being repositioned [3].
Other authors explained, on anatomical and developmental (embryological) grounds, why they use the deep-plane facelift to treat neck aging. Their reasoning is that this method is directly linked to the movement of the soft tissues of the midcheek, so it can maximize improvement in the neck [4].
A review introducing the extended deep-plane facelift explained that four main supporting ligaments are released (the zygomatic cutaneous, masseteric cutaneous, mandibular cutaneous, and cervical retaining ligaments), and that the composite flap is repositioned to add volume to the midcheek and the area near the angle of the jaw [5]. In the neck, it stated that the focus is on extending the deep-plane dissection of the platysma, creating hammock-like support with the platysma to hold up the submandibular gland, sharpening the jawline, and reducing the need to open the neck directly [5].
When an incision under the chin is added
Surgery under the chin, in which the platysma at the center of the neck is stitched directly, is also a method frequently discussed in neck surgery. The authors who introduced the vertical neck lift stated that they do not routinely perform surgery on the platysma at the center of the neck, because it interferes with vertical repositioning [3].
The same authors explained that many patients with an aging face are good candidates for a vertical neck lift alone, but that there are also specific indications for adding surgery under the chin [3]. The extended deep-plane approach also focused on reducing the need to open the neck [5]. Whether an incision under the chin is needed is judged by looking at the anatomical condition of the neck.
Risks and limitations
It has been pointed out that in neck surgery, too, new complications have appeared with the arrival of minimally invasive techniques [2]. This is why it cannot be assumed that a less invasive method always carries less risk.
The authors who introduced deep-plane neck surgery described anatomical landmarks and technical details at length to achieve safe and consistent results [4]. In addition, there are general risks such as bleeding and a collection of blood under the skin (hematoma), infection, scarring, changes in skin sensation, nerve injury, and asymmetry. Most of the sources reviewed here are reviews presenting the authors' own methods and experience, so they do not include evidence comparing outcomes or how long results last between methods in numbers.
What to check during your consultation
The cause of a sagging neck differs depending on whether it lies in the skin, the fat, the platysma, or the deeper structures. It is best to have the condition of each layer checked through an examination and to discuss whether the neck should be addressed together with the lower face or on its own.
- Which layer is the main cause of your sagging neck
- Whether it needs to be combined with a facelift
- Whether an incision under the chin is needed, and why
- How much fat will be removed and the risk of overtreatment
- What recovery involves and how complications are managed
Frequently asked questions
- Will removing neck fat alone fix a sagging neck?
- The literature notes that cosmetic problems in the neck often result from overtreating the shallower structures and undertreating the deeper ones [2]. For this reason, whether to treat only the fat or also the platysma and deeper structures should be decided through an accurate assessment [2]. It is best to have the condition of your neck checked through an examination.
- Does a neck lift have to be done together with a facelift?
- The vertical neck lift and the extended deep-plane approach carry the deep-plane dissection of the face down into the neck, moving the skin, SMAS, and platysma together [3, 5]. There is also an explanation that the deep-plane approach helps improve the neck because it is directly linked to the movement of the soft tissues of the midcheek [4]. However, whether the neck can be treated on its own depends on where the sagging is and how severe it is.
- Does the center of the neck always have to be opened?
- The authors who introduced the vertical neck lift do not routinely perform surgery on the platysma at the center of the neck, and they considered many patients to be good candidates for the vertical neck lift alone [3]. However, they also described specific indications for adding surgery under the chin [3]. Whether it is needed is judged by looking at the anatomical condition of the neck.
References
- Charafeddine AH, Couto RA, Zins JE. Neck Rejuvenation: Anatomy and Technique. Clin Plast Surg. 2019.PubMed 31514809DOI
- Gordon NA, Paskhover B, Tower JI, et al. Neck Deformities in Plastic Surgery. Facial Plast Surg Clin North Am. 2019.PubMed 31587772DOI
- Jacono AA, Talei B. Vertical neck lifting. Facial Plast Surg Clin North Am. 2014.PubMed 24745389DOI
- Gordon NA, Adam SI. The deep-plane approach to neck rejuvenation. Facial Plast Surg Clin North Am. 2014.PubMed 24745388DOI
- Jacono A, Bryant LM. Extended Deep Plane Facelift: Incorporating Facial Retaining Ligament Release and Composite Flap Shifts to Maximize Midface, Jawline and Neck Rejuvenation. Clin Plast Surg. 2018.PubMed 30268241DOI
This article is an English translation of general health information that DOY JUN Plastic Surgery compiled in Korean from the summaries (abstracts) of papers in international academic journals. Treatment methods and results vary depending on each person's condition, so please consult a specialist for an accurate diagnosis and treatment plan.
