While great advancements have been made in addressing many aspects of the aging face including the midface and jawline, many of the current techniques fail to completely address the lower half of the neck. This region is easily visible and improvements in this area can be critically important to the overall success of facial rejuvenation surgery. Standard face/ neck lift procedures coupled with submentoplasty can effect great improvements in the upper neck and cervicomental angle in the large majority of patients. Nonetheless, in some patients, especially those with pronounced lower neck vertical banding and/or horizontal pleating and deep lines, additional procedures may be beneficial. Standard multivector face/neck lifts as well as deep plane face/neck lifts may incompletely address these pathologies in the lower half of the neck. Two additional neck lifting procedures, the horizontal neck lift and vertical neck lift, may be used, based on individual patient findings. In selected patients, these additional procedures used either concurrently with a face/neck lift or alone in specific situations can be instrumental in the success in of facial rejuvenation surgery.

59.2 Pathophysiology of the Aging Neck

The aging process is dependent upon genetic, anatomic, and environmental factors. The most commonly held theory of cervicofacial aging is one of progressive gravimetric soft tissue descent [9]. With repeated gravitational forces, skin and soft tissue stretch off the bony skeleton, leading to the development of folds, rhytids, and volume loss. However, cervicofacial aging is much more complex and a proper discussion involves dividing the components of facial and neck anatomy into basic categories, including skin, subcutaneous tissue, fascia/muscle, and bone.

59.2.1 Aging Skin

The skin is subject to both extrinsic and intrinsic aging processes. Within the skin, there is thinning of the epidermis, disorganization and reduction in the amount of collagen fibers within the papillary and reticular

dermis, including loss of Type I collagen and increased Type III collagen fibers. There is also effacement of rete ridges within the epidermal–papillary dermal junction. Further contributing to the aging appearance is the appearance of dyschromias from accumulation of previous solar damage. This solar elastosis and disorganization leads to thinning of the skin and development of static rhytids. Accumulated exposure to ultraviolet (UV) A and B light leads to direct DNA damage as well as the formation of free radicals which, with the decreased levels of antioxidants with advancing age, are less easily buffered. Furthermore, dehydration of the skin and reduction in sebum production by sebaceous glands leads to further thinning and rhytid formation.

59.2.2 Aging Soft Tissue

Accompanying the changes in the level of the skin are changes in the deeper structures. With advancing age, there is a concomitant decrease in basal metabolic rate, leading to increased adipose tissue. Proportionate fat increases are seen in the face beginning in the fifth decade [9]. Fatty tissue accumulation occurs in depot areas of the body beneath the superficial fascia. In the face and neck, they are located in the periorbital, malar, and submental regions. Progressive fascial and ligamentous laxity leads to decreased support of the adipose tissue resulting in a relative increase in volume of the lower third of the face. While volume loss is a predominant theme in the majority of aging patients, in some, there is increased lyposis, leading to jowl, submental, and lower neck fullness. In these patients, it is important to address the volume accumulation, but also to remain cognizant that adipose tissue may camouflage the aging of other tissues, such as platysmal banding or submandibular gland ptosis.

In many women, as estrogen levels decrease with the onset of menopause, there is a further decrease in superficial fat deposits resulting in thin, poorly supported skin which is easily pulled by the deeper fat. There can also be a loss of subcutaneous adipose tissue resulting in volume depletion and hollowing. There is also increased elasticity of the submuscular aponeurotic system (SMAS) supporting framework leading to