as it better confers the principle that a rhytidoplasty, although offering some improvement in the lower and midface, is especially efficacious in addressing jowl–mandibular elastosis and the upper third of the neck. Although detailed discussion of rhytidoplasty techniques are beyond the scope of this chapter, the different ranges of rhytidoplasty employed by the primary author and others reflect different degrees of subcutaneous undermining, the length and location of skin incisions, and the degree to which the SMAS/ Platysma complex and thus the upper third of the neck can be addressed.

The primary author employs a multivector SMAS/ Platysma suspension technique with variations depending on the needs of a particular patient. Extensive sub-SMAS/Platysmal undermining is not performed. It is felt that this does not offer a significant advantage in lifting the SMAS/Platysma complex, but does increase the risk of facial nerve branch injury. In fact, when resuspending the SMAS/Platysma complex, the lift of the inferior portion of the SMAS/ Platysma is only along the nonundermined portion. A more complete, uniform lift is achieved without any undermining. With the multivector suspension, the direction of vector pull is determined by the tissue pathology. Figure 59.7 shows the various vector directions for the SMAS/platysma imbrication or plication. In general, the most inferior SMAS suture vector focuses on improvement of the submental area, cer- vico-mental angle, and upper neck with a primarily vertical direction of suspension superiorly at the angle of the mandible. For many patients seeking

Fig. 59.7 Demonstrating the different vectors of pull in the multivector SMAS plication

improvement in the neck selection of appropriate face/ neck lifting techniques are of utmost importance.

59.9 Special Neck Lifting

Although the upper neck and cervicomental angle can be greatly improved in the large majority of patients through face/neck lifting, submentoplasty and liposculpture, additional procedures may be beneficial. Standard multivector face/neck lifts as well as deep plane face/neck lifts may incompletely address 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. Both of the procedures may be performed concurrently with a face/neck lift, subsequent to a face/neck lift in a patient who desires further improvement, or as the sole surgical procedure in patients without a prior history of surgery.

59.9.1 Vertical Neck Lift

While the classic face/neck lift provides generally adequate results when combined with a submentoplasty/ platysmaplasty, the lower half of the neck may have insufficient improvement in a certain percentage of patients. Most patients presenting for face/neck lift/ submentoplasty display most of the aging in the upper half of the neck. As much as 30% of the face/neck lift population display considerable aging in the lower half of the neck, most commonly characterized by vertical platysmal bands extending to the clavicle. This type of patient can sometimes display inadequate improvement in the vertical bands in the lower half of the neck postoperatively. Until recently, we have provided very little in the way of a solution to this dilemma.

In the past few years, the author (HM) has utilized an extension of the classic face/neck lift along the hairline to create massive undermining in the lower half of the neck, extending almost to the midline. In doing this, one is able to affect a posterior pull on the platysma onto the firm and less mobile sternocleidomastoid fascia. In doing this, one can achieve a more dramatic improvement of the vertical bands in the lower half of the neck. This procedure has been coined

“The Vertical Neck Lift.” While not perfect, it is the best, in our experience, in improving the platysmal bands of the lower half of the neck. This also seems to help lower and midneck central vertical skin pleating.

The candidates for this type of procedure are limited. If a woman wants to wear pulled straight back, this scar is visible and may not be desirable. Vertical neck scars do not heal as well as horizontal neck scars and are more prone to hypertrophic scarring. Another limitation is a patient with a high posterior hairline. In a patient with a high posterior hairline, the incision cannot be carried far enough inferiorly to effect the desired improvement in the vertical bands of the lower half of the neck. The ideal patient has a very low posterior hairline and does not wear their hair straight back.

The vertical neck lift addresses platysmal banding of the inferior neck as well as vertical skin pleating (Fig. 59.5). Commonly, this procedure is done in conjunction with the face/neck lift. The skin incision is carried inferiorly from the postauricular aspect of the face/neck lift along the hairline (Fig. 59.8). It is extremely important to preoperatively evaluate the patient’s hairline and inquire about hairstyle preference. The inferior aspect of the incision is the inferior border of the hairline, and the ideal patient is one with a low posterior hairline. Patients with a high posterior hairline are poor candidates for the vertical neck lift as the access provided by limited incision will be inadequate to reach the posterior platysmal border and improve inferior platysmal banding and skin pleating. In addition, patients who prefer to wear their hair in a pulled-back fashion should be advised that this may lead to scar visibility and a postoperative hairstyle change may be advisable.

The skin flap is undermined and elevated well past the posterior border of the platysma (Fig. 59.8) about 2–3 cm from the midline. This extensive undermining allows the inferior platysma to be resuspended posteriorly and superiorly to the fascia of the sternocleidomastoid where it is more stable (Fig. 59.8). This resuspension allows for improvement of the inferior portion of the platysmal bands which would be inaccessible in a traditional face/neck lift.

In addition to improved platysmal suspension, another important advantage of the vertical neck lift is the improvement in redraping of the lower neck skin flap. A significant amount of posterior neck skin may be removed which permits a smoother contour with a more subtle transition to the nonundermined neck skin (Fig. 59.8).

One might be surprised at how much additional skin can be removed in the neck when combined with the classic face/neck lift. Certainly, such a large amount of skin removal must contribute to a more dramatic change to the lower half of the neck in the short and long term.

It is very important for surgeons to realize that the vertical neck lift can be done as an additional procedure long after a classic face/neck lift. For example, the surgeon and patient may see a lack of satisfactory improvement in the lower half of the neck after 1 year and can easily perform this procedure under local anesthesia. It is possible that an adequate face/neck lift with good results at 50 years of age can persist in the upper half of the neck while the lower half of the neck shows undesirable results again at 55 years of age. One can then do an isolated vertical neck lift bilaterally and, even at times, unilaterally. In the senior author’s experience, the classic limited neck lift for the upper half of the neck is not effective as an isolated procedure; however, the vertical neck lift is effective as an isolated procedure for the lower half of the neck.

The most significant disadvantage of the vertical neck lift is the resultant scar. It is essential that the skin closure be performed in a tension-free manner with longterm absorbable or permanent dermal sutures. If there are early signs of scar hypertrophy or keloid formation, then this should be promptly addressed. Other disadvantages include a longer surgical time, potential for more neck ecchymosis, and the creation of a long, narrow postauricular skin flap. It is generally agreed that long, narrow skin flaps are more prone to epidermolysis, less optimal wound healing, and even regional necrosis. Although skin flap necrosis may be possible, the primary author has not yet experienced this. Figure 59.8 demonstrates the degree of improvement that may be achieved with the vertical neck lift. Patients have uniformly recognized the value of the vertical neck lift as the improvement is substantial and not subtle.

59.9.2 Horizontal Neck Lift

There is a group of patients where a significant aging process occurs in a horizontal direction rather than the vertical direction described above. Certainly the vertical platysmal banding is more common than what is

Fig. 59.8 (a) Preoperative markings for the vertical neck lift. The preauricular portion is the same as the classic face/neck lift while the postauricular incision extends inferiorly along the postauricular hairline. (b) Intraoperative showing elevation of the postauricular skin flap achieved with the extended vertical neck lift incision. (c) Intraoperative demonstrating the access to the SMAS/platysma complex after subcutaneous undermining. (d) Intraoperative showing the inferior extent of the platysmal plication achieved with the vertical neck lift. (e) Intraoperative demonstrating the postauricular skin redraping without any bunching or contour irregularities. (f) Preoperative patient with extreme inferior platysmal banding. (g) Postoperative after a vertical neck lift demonstrating virtual elimination of the platysmal banding

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described relating to the horizontal neck aging. This group of patients demonstrates deep, long, multiple horizontal neck lines as well as redundant horizontal neck skin between these “etched-in” lines. A posterior pull on the neck, in this type of patient, will not provide the desired result. The senior author has seen this

group of patients in the past without daring to perform an excision of skin and sometimes fat by creating a visible scar line across the lower, central neck. With some trepidation, this procedure is carried out with the idea that a meticulously approximated 12–17 cm scar is less conspicuous than the more conspicuous deep

horizontal “etched-in” neck lines already present in this group of patients. The vertical height of the elliptical excision in the horizontal neck lift may range from 2–4 cm. The senior author has never found the resulting scars to be a detriment to doing this procedure because the improvement is so much more rewarding.

The horizontal neck lift is used primarily to improve lower neck horizontal pleating or excess skin and to improve the number of deep horizontal skin furrows, as demonstrated by the patient in Fig. 59.9a. In the primary author’s practice, the horizontal neck lift is commonly performed as a sole procedure in a patient with horizontal neck laxity after a prior face/neck lift. However, in certain circumstances, it may be performed concurrently with a face/neck lift and submentoplasty. A central neck vertical excess of skin and/or fat will not be adequately addressed with a posterior–superior vector of pull achieved with a traditional face/neck lift or even the vertical neck lift. However, the horizontal neck lift is an excellent means by which this difficult problem may be improved.

The technique involves an elliptical excision of the horizontal neck redundancy. Determination of the amount of skin to be resected is done using a pinch technique. The ellipse is centered on an existing horizontal neck furrow. The height of the ellipse is determined by grasping the excess skin until the neck is taut with the head in a slightly extended position (Fig. 59.9). The resulting amount of skin to be removed is at least 2 cm and, much more commonly, around 4 cm. The resulting scar from the elliptical excision will replace a preoperative existing horizontal neck furrow. Excision of the skin is then performed along with a thin layer of subcutaneous adipose tissue.

Depending on the individual patient findings, open subcutaneous liposuction may be performed in the exposed area, as needed, with a #3 spatula cannula. Further closed liposuction in surrounding areas can be accomplished, if needed. A microliposuction cannula may be used to feather the periphery of the ellipse or the area of closed liposuction to create a smooth transition zone. Additionally, if vertical platysmal bands are encountered,

Fig. 59.9 (a) Preoperative patient with deep horizontal neck furrows and a horizontal excess of lower neck skin. (b) Preoperative marking of the ellipse in the horizontal neck lift. The extent of vertical skin excision is in the surgeon’s judgment but should be aggressive. The neck is extended and the excess horizontal neck skin is grasped with a forceps or Allis clamp until the skin contour is smooth. (c) Intraoperative just after incision of the ellipse demonstrating the amount of skin that can be safely removed. (d) Postoperative demonstrating a dramatic improvement in the depth of horizontal neck furrows as well as elimination of the horizontal excess neck skin

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