South Florida Necklift

Introduction
The necklift is a surgical procedure that rejuvenates the neck. This is an operation that helps to improve the neck contour in certain patients that may not need the comprehensive facial rejuvenation that a facelift provides.

The aging seen in the neck begins in the late twenties. However, visible changes usually become apparent in the late thirties. These changes are due to transformations that occur in the skin, fat, and muscles of the neck.

Figure1

Female demonstrating the beginning of the neck aging process. There is mild platysma descent and skin laxity.

The skin is one of the first components that begins to age. The amount and quality of the collagen and elastin, both important structural proteins in the skin, begin to decrease. This allows for weakening and thinning of the skin. The skin looses elasticity and increases in laxity (Figure 1). You can test your skin's laxity by pinching the area under the chin, pulling it and then letting it go. Skin that is lax will not snap back.

The platysma muscle originates in the lower face and runs down the entire neck. This muscle descends, in both the face and neck, with age. It can sometimes cause the bands that appear in the front of the neck.

The aging neck: redundacy, inflation, and muscle descent
The aging neck is one of the most challenging areas to treat in facial rejuvenation surgery. The transformations that occur in the neck as a result of the aging process are increasing skin redundancy, inflation, and muscle descent. The surgeon should plan and address these during the surgery to maximally improve the neck contour.

The platysma muscle runs from the lower face down into the neck. With aging, this muscle descends and may cause the neckbands that are commonly seen in the neck. In addition, the loosening of the muscle may add fullness in the neck below the jawline (Figures 2, 3). The necklift procedure addresses the muscle by tightening it centrally below the chin and laterally near the corner of the jawbone.

Figure2

Female patient demonstrating an aging neck. There are platysma neck bands and skin laxity.

Figure3

Same patient, oblique view.

The submental area, just underneath the chin, is an area where the accumulation of fat can cause an inflation in the neck. Fat removal should be performed judiciously in order to sculpt the neck adequately, yet maintain a natural appearance. Overzealous fat removal in this area can skeletonize the neck and allow the underlying neck structures to be visible through the skin.

Figure 4

Female patient with an aging neck.

Over time, the neck skin can loose elasticity and become lax. This leads to a redundancy of the skin over the neck. While the necklift procedure tightens the underlying neck muscles and removes the excess skin redundacy, it does not address the inherent laxity that the person's skin may have (Figure 4).

The person with excessive skin laxity may have a less then ideal result in the neck as a consequence. This patient may benefit from certain skin tightening non-invasive procedures after the surgery. It is a well-known fact that necklifts may not satisfy all patients in the neck area. The reason is usually excessive skin laxity, which surgery cannot completely address.

Technique and Incisions
The necklift procedure treats the aging neck by removing the fat accumulation under the neck, tightening the neck muscles and then removing the excess skin. The procedure is performed through three small incisions. The first incision is below the chin, hidden in the small crease that lies just behind the chin. Through this incision, the fat is removed and the platysma neck muscles are tightened (centrally). The other two incisions are placed behind each ear. These are used to tighten the neck muscles laterally and to remove the excess skin. By tightening the platysma centrally and laterally, maximum tightening of the underlying tissues is achieved. The incisions are all placed in hidden areas. Once healed, they are virtually imperceptible.

Are you a candidate for the necklift
The majority of patients that undergo the necklift operation do so in their early forties and on (Figures 5, 6). Occasionally, patients with premature neck aging or weight loss will undergo the surgery at an earlier age. Patients that have had a facelift, and are content with the facial rejuvenation but are discontent with the neck rejuvenation are also good candidates for the necklift.

Figure5

Female with aging neck. There is some platysma descent and moderate skin laxity.

Figure6

Same patient after undergoing a necklift procedure by Dr. Bustillo.

People are many times confused about what exactly a necklift corrects (Figures 7, 8). The goal of a necklift procedure is to rejuvenate the neck. The face and jowls are not rejuvenated with a necklift. The facelift is the procedure of choice for rejuvenation of these two areas.

Figure7

Female with a history of a previous facelift by another surgeon who now experiences a sagging neck.

Figure8

Same patient after a necklift procedure by Dr. Bustillo.

The decision about having the necklift operation is a very important and personal one. You should consult with your surgeon and your family. For most people that undergo the procedure, the results are life changing. Patients describe an increase in confidence and boost in self-esteem. They feel rejuvenated and feel more comfortable in social settings and in pictures.

The ideal patient must have the proper expectation before undergoing surgery. Although with the minimal incision necklift technique, results are better than they ever were, there are still limitations. It is important that the patient have a good understanding of what can be achieved. Clear communication between the patient and the surgeon is very important.

Surgeons are human and therefore are not perfect. While most necklift patients enjoy the benefits of an improved neck, it is important to remember that surgery, like all other human actions, is not perfect. A skilled surgeon can achieve near perfection. However, one must remember that the skin and soft tissues the surgeon works with can have inherent laxity and weakness.

Consultation
The consultation begins with a discussion about the specific issues and concerns that the patient may have. It is important to discuss whether the neck aging has occurred slowly over time or recently in the last several years. Any recent weight loss or plans for weight loss are discussed so that the surgery can be planned at the appropriate time.

A thorough physical examination is performed. The neck is examined and palpated. The amount of neck fat is determined and then the amount of muscle descent is examined. The skin laxity is tested. The laxity will help to determine the degree of correction that the patient will achieve.

The patient and I then have a discussion about the result that I believe can be achieved with surgery. The patient should understand exactly what the necklift procedure will achieve for them, so that an informed decision can be made. The procedure is explained in detail and all questions are answered.

Preparation
All patients are required to obtain pre-operative labs and a medical clearance from their primary care physician prior to surgery. All aspirin, anti-inflammatory products (naproxen, ibuprofen), and vitamins such as A, ginkgo biloba, and St. John's wart should be discontinued ten days before surgery because they may interfere with blood clotting and cause bruising. Alcohol should also be avoided for five days before surgery to avoid swelling. Patients are required to start high dose vitamin C two weeks before and two weeks after to help with the healing and to reduce bruising.

Anesthesia
The necklift procedure can be performed under different anesthesia modalities, depending on the patient and the adjunctive procedures being performed. If the patient is having the necklift operation alone, it may be done with either local anesthesia or IV sedation anesthesia. However, if the necklift is being performed in combination with eyelid surgery, either IV sedation or general anesthesia is used. Certain patients may require general anesthesia for safety reasons. The necklift procedure takes about one and a half hours to perform.

Risks
The necklift operation, like all surgery, does have risks aside from those of anesthesia. The highest risk patients are smokers. Patients who smoke should refrain from smoking for approximately two weeks before the surgery. The nicotine patch is not a substitute for smoking cessation as far aesthetic surgery is concerned. Nicotine causes the small blood vessels to become narrower, which decreases the blood flow to the skin. The potential complication in a smoker is the death of the neck skin, resulting in a poor outcome with facial scarring and possible infection. The necklift surgery will not be performed on an active smoker.

A hematoma is a collection of blood that can accumulate under the skin. Although rare, it can occur after a necklift. The risk of hematoma is about 1%. The treatment usually entails draining it in the office. Most patients that have a hematoma after surgery recover well without any complications. Infections after necklift surgery are also rare. Patients are given antibiotics prior to surgery and after surgery to help prevent infections.

Recovery
The patient is discharged home the same day after surgery. The first night should be spent relaxed. Activity should be kept to a minimum. A liquid diet is best for the first eighteen hours after anesthesia. The head should be kept elevated using two pillows to help reduce swelling.

The neck will be wrapped with a bandage used to keep the skin flat. Pain should be minimal. Tylenol is usually enough to control any minor discomfort. Additional pain medication will be provided, in the event that it is needed. Any significant pain should be reported to Dr. Bustillo immediately, as this may signal bleeding under the skin. If a blepharoplasty was performed, some mild bruising may be visible around the eyes.

The patient is then seen the morning after surgery. The bandage will be removed on the first day after surgery. It is normal for some bruising to appear in the neck. A small bandage is then worn for five days while the healing occurs. On the fifth post-operative day, the small stitches under the chin are removed. Patients can usually shower and wash their hair after this second visit.

Most patients return to work and daily activities about one week after surgery. Seventy percent of the swelling resolves in the first two weeks. It is recommended that physical activity, such as running or lifting be resumed three weeks after the surgery. The remainder of the swelling can take up to two months to completely resolve. This remaining swelling is imperceptible.

The final results of the surgery may not be completely evident until several months after the surgery. The results of a necklift operation usually turn back the clock approximately ten years and the results last about ten years. Most patients who undergo neck rejuvenation surgery are extremely happy with the results.

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