they may be addressed through vertical or horizontal resection and imbrications/plication as described previously in the discussion of submentoplasty.

The advantages of the horizontal neck lift include the ability to use local anesthetic if done as a sole surgical procedure, the ability to reduce lower neck horizontal pleating and excess skin, the ability to reduce the severity and decrease the number of deep transverse neck furrows, and the fact that, if properly closed, the scar is generally not as deep or visible as the original horizontal furrow it replaces. It is extremely important that the incision be closed meticulously with numerous dermal sutures and the skin edges everted with vertical mattress sutures. Steri-Strips™ should be used for several weeks after the sutures have been removed. The patient should also be instructed to avoid extreme neck extension during the recovery period.

The disadvantages of the horizontal neck lift include restricted neck extension if the height of the excised ellipse is too much, a horizontal neck scar, and the possible need for repeat excision of skin if the initial excision is too conservative. This additional horizontal excision is not uncommon, as the surgeon tends to be conservative in his initial horizontal neck lift (Fig. 59.9).

The patients on whom the author (HM) has performed horizontal neck lifts, have uniformly been very satisfied and realize the obvious improvement in the lower half of the neck. These procedures have most commonly been done under local anesthesia when they are not combined with other procedures.

A special circumstance is one in which a patient may have both extreme vertical neck skin excess and vertical platysmal banding combined excess skin in a horizontal direction with horizontal rolls of excess fat in the lower neck (Fig. 59.10). If a patient has this combination of findings, they can undergo one surgical procedure that includes submentoplasty, classic face/neck lift, and a both a horizontal and vertical neck lift. Figure 59.10 shows the significant degree of postoperative improvement possible using the full spectrum of surgical techniques. Without the additional neck lifting provided by both the vertical neck lift (to improve the inferior platysmal banding) and the horizontal neck lift (to address both the horizontal skin and fat excess as well as the deep horizontal neck creases), the postoperative result would have been suboptimal.

These two simple, easily performed procedures of the vertical neck lift and horizontal neck lift have added enormously to the results one can achieve in a

limited group of aging neck patients, more specifically the lower half of the neck. These are easily added to any surgeon’s armamentarium and can be provided to patients with problems in the lower half of the neck.

59.10 Clinical Pearls and Pitfalls

The importance of an individual patient approach to the aging neck cannot be overemphasized. There is not a “one size fits all” approach to rejuvenation. In order to optimally treat each patient, all aspects of patient aging must be understood and addressed.

The patient consultation is the first impression of you practice and will set the stage for future expectations. Besides instilling a sense of professionalism and comfort in the prospective patient, the consultation provides the surgeon with the opportunity to educate his patient on his or her specific pathology. A better understanding of pathology will help the patient understand the surgeon’s recommendations and will also increase the likelihood that the surgeon’s treatment recommendations will be followed. Patient wishes must be respected and no unrealistic promises be given. If the patient stresses a natural, conservative postoperative appearance, this should be clearly documented in the patient medical record. It is not uncommon to have a patient, previously espousing a natural look, to return wanting a more extreme degree of improvement. Documentation during the initial consultation can help remind both the surgeon and the patient of any earlier discussions.

A systematic approach to facial analysis is essential in rejuvenation treatment. In this endeavor, a standardized patient evaluation form is extremely valuable. Such an approach helps develop a complete pattern of evaluation and creates a qualitative analysis and quantitative record of patient features and the degree of aging which serves to individualize patient analysis and records. The evaluation form not only provides a valuable intraoperative reference, but greatly facilitates a review of patient findings long after the initial consultation.

Any preoperative asymmetry or unusual findings must be documented and discussed with the patient. Standardized photographs help to provide a record of the preoperative appearance. Patients frequently forget their “old face” and these photos can help remind them of previous pathology. It is common for lines and skin lesions on the face and neck to move to a different

c

b

d

position postoperatively and reviewing the preoperative photos with the patient can help remind him or her that this is not a surgical complication.

Remember the Horizontal Neck Lift for improving the supraclavicular redundant neck skin. A long horizontal scar in a previous horizontal neck crease is far

more aesthetic than horizontal pleats of supraclavicular or midneck skin.

Do not promise great results in the aging lower half of the neck. Do not forget that the Vertical Neck Lift is the path toward your best lower neck skin redundancy and supraclavicular platysmal banding.

It is important to avoid the temptation to overcorrect any patient pathology. This can lead to excess wound tension with scar widening as well as an unnatural, “pulled” appearance. It is far better to be conservative and to do a small secondary procedure in the future than to have a complication from trying to be too aggressive initially. Any early signs of complications, such as scar hypertrophy or keloid formation, or skin flap compromise, must be quickly diagnosed and treated. Frequent postoperative patient appointments help not only follow the surgical recovery, but also to convey a sense of patient importance. A solid surgeon–patient relationship will help carry the patient through any postoperative setbacks and ensure a successful postoperative result with a satisfied, happy patient that will be a positive reflection to the practice.

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