How to Optimize the Neck Lift

An investigative article published in the Aesthetic Surgery Journal examined the neck lift and how to create desired results for facial rejuvenation in patients.¹

The goal of the study was to create a quantitative analysis of the management of supraplatysmal and subplatysmal structures of the neck by comparing patients’ outcomes in the reduction of cervical contouring. With this information, the researcher wanted to guide clinicians in the surgical planning process by growing the understanding of modification of each subplatysmal element, and to optimize neck lift techniques. 

“The indication for a deep cervicoplasty was determined if there was an imbalance between the volume and position of the subplatysmal contents of the anterior neck and the lower facial mandibular skeletal capacity,” the author wrote.

If the patient was younger, the author treated them with an isolated neck lift and if they were older with subplatysmal volumetric imbalances and changes in the mid and lower face, a concomitant sub-superficial musculoaponeurotic system (SMAS) face lift with a deep cervicoplasty was performed. If the patient had strong skeletal support while also having minimal excess subplatysmal volume were treated with a lateral face lift. 

The first step in the author’s process to decide the necessary subplatysmal procedures that need performed is to elevate the platysma, fully exposing the deep fat and submandibular glands. The second step is to evaluate the deep fat and submandibular gland to determine the impact mass-producing structures have on the anterior neck contours. The third step is committing to modify the submandibular gland if it is enlarged or malpositioned, as a decision needs to be made before modifying the other structures of the neck and if the glands aren’t reduced, the physician must be conservative in the management of the other subplatysmal structures to ensure that a balanced, smooth contour and transition is created.

From May 2017 to May 2019, the author performed 254 face and neck lift procedures. Of the 254 patients who received face and neck lifts, 225 were female and 20 were male with an average age of 52 years old. For 194 patients this was their first neck surgery and the other 52 patients had previous neck treatments such as face/neck lifts, suction assisted liposuction, energy devices, mesotherapy, or cryotherapy.

There were 152 patients examined that underwent deep cervicoplasty, 134 of those patients underwent concurrent face lift and 18 had an isolated neck lift. The other 93 patients had a lateral only approach to neck rejuvenation. The patient’s results were measured by how many times the change of each surgical maneuver was used and the amount of supraplatysmal and subplatysmal volume removed was determined using a volume-displacement technique. 

The results found that the total mean volume removed from the supraplatysmal and subplatysmal planes during deep cervicoplasty was 22.3 cm³ and 73% of that total was subplatysmal volume. All patients saw a reduction in subplatysmal volume. 

The other volumes broke down in the following:

• 96% of patients saw a deep fat volume reduction by a mean of 7 cm3.
• 76% of patients achieved a reduction in submandibular gland volume by a mean of 6.5 cm3.
• 70% of patients had their anterior digastric muscle volume reduced by a mean of 1.8 cm3.
• 32% of patients had reduction in the perihyoid fascia volume by a mean of less than 1 cm3.
• 14% of patients had reduction in the mylohyoid volume by a mean of less than 1 cm3.
• 34% of cases the anterior digastric muscles were plicated to reposition the hyoid.
• 40% of patients had a supraplatysmal fat reduction of 6.3 cm3.

The most common adverse event (AE) observed was transient dysfunction of the lower lip depressors in 12 patients and all patients lower lip weakness resolved between 2 to 14 weeks. The lip depressor dysfunction in 1 patient was managed using neurotoxin to the unilateral unaffected lip depressors to help create a symmetric smile during the recovery period.

Four patients experienced sialoceles and these happened during a period when the use of neurotoxin injection to the submandibular remnant was discontinued. To treat this, 2 cases were resolved with repeated aspiration and neurotoxin injections and the other 2 had a drain placed and a neurotoxin injection. All 4 patients were placed on scopolamine for the antimuscarinic effect, according to the author.

A major supraplatysmal hematoma occurred in 1 patient and required surgery and two other delayed minor hematomas occurred in the early postoperative period which were managed in office with needle aspiration and placement of a small hemostatic net.

There were also 3 patients that underwent revisional surgery to treat contour irregularities in the submental neck region and in 2 patients experienced irregularities in the supraplatysmal space because of uneven sculpting of the supraplatysmal fat. One patient required secondary surgery to reduce the anterior digastric muscles. Overall, 19 patients experienced AEs.

The criteria for a beautiful neck, according to the author, has been most credited to Ellenbogen² and have been reduced to 3 components³:

1. Distinct inferior mandibular border.
2. Cervicomental angle of 105° to 120°.
3. Subhyoid depression- if a sharper neck contour is the goal. 

Understanding these characteristics will help guide physicians in the direction needed to create a good result. The author says that when a patient’s aesthetic is less than optimal because of volume discrepancy causing unbalance and less neck contour, it is often because of the surgeon’s failure in understanding anatomic findings and the patient’s goal. Each procedure has to be customized to the patient.

A successful surgery of the subplatysmal structures can be achieved with 3 distinctive objectives.

A large volume reduction of the anterior neck volume through removal of deep central neck fat and the submandibular glands.1 A small volume reduction of the mylohyoid and anterior digastric muscles and perihyoid fascia to flatten the submentum, deepen the obtuse cervicomental angle, and smooth the transition from the submental triangle to the submandibular triangle.1 A hyoid repositioning to a more favorable cephalad and posterior position with release of the perihyoid fascia and mylohyoid muscle in combination with an anterior digastric muscle plication.¹

“The impact of each surgical step in isolation, as well as anticipating the consequence of each subsequent surgical maneuver, must be keep in mind to optimize the outcome and avoid an imbalance between the neck and face,” the author concluded.

Disclosures:

The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Reference:

1. O’Daniel TG. Optimizing outcomes in neck lift surgery. Aesthetic Surgery Journal. 2021;41(8):871-892. doi:10.1093/asj/sjab056

2. Ellenbogen R, Karlin JV. Visual criteria for success in restoring the youthful neck. Plast Reconstr Surg. 1980;66(6):826-837. doi:10.1097/00006534-198012000-00003

3. Ceravolo MP. Invited discussion on: aesthetic submandibular gland partial resection—a systematic review and critical analysis of the evidence. Aesth Plast Surg. 2020;44(2):349-353. doi:10.1007/s00266-020-01617-1