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14 Revisional and Secondary Neck Lifts
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Ashley N. Boustany, Vickram J. Tandon, and Sumner A. Slavin
Abstract
The neck contour and laxity are common concerns
in patients seeking facial rejuvenation. Patients
seek a secondary neck lift due to the unrelenting
natural aging process, unsatisfactory results, early
recurrence, or iatrogenic deformities. It is important to identify the patient’s goals and determine
the etiology. Technical challenges arise due to altered anatomy in the previously operated field and
scarred tissue planes. One must strategically plan
incision placement for optimal scar camouflage
and prevention of complications. Acquired deformities should be approached methodically. Longevity of results may be optimized with treatment
of the deeper planes and maintenance regimen adjuncts.
Keywords: revision neck lift, secondary neck lift,
neck lift complications, aging neck, rhytidectomy
longevity, reoperative neck lift
Key Points
●
Revisional and secondary neck lifts present challenges related to incision placement, fibrotic tissue planes, altered anatomy, and a potentially
older patient population.
●
Revisional neck lifts are performed when results
are unsatisfactory or in the presence of softtissue complications.
●
Secondary neck lifts are performed when initial
results were satisfactory, but progressive loss of
correction occurs due to the natural aging process, often years following the primary procedure.
Coexisting deformities related to the primary
rhytidectomy may also be present.
●
Patients should be counseled on risk factors for
early recurrence including poor skeletal support,
significant tissue laxity, and adv anc ed age.
●
Patient goals should be clearly elucidated with
an accurate ident i fication of the anatomical
●
Anterior platysmal bands are common. Treatment often requires a submental approach with
platysmaplasty, along with maximal preservation of skin flap thickness.
14.1 Revisional versus Secondary
Rhytidectomy
The reoperative neck lift carries certain challenges
that necessitate additional attention, particularly
when the primary technique is unknown or in the
presence of significant scarring or deformity. The
surgeon must first identify patient goals and diagnose the anatomical etiology. Caution should be
employed as the dissection planes are often obscured and critical structures may be repositioned.
Patients should be counseled on the potential for
increased complication profiles. Revisions may be
reduced by maintaining an awareness of the
potential sequelae. Narasimhan et al found the
most common reason for reoperation was recurrent platysmal bands and jowling.
1
Skouras et al
identified hairline malposit ion as the primar y
motivation.
2
Despite the additional complexity,
patient satisfaction outcomes remain high and
adverse outcomes may be minimized with proper
surgical technique.
3,4
14.1.1 Revisional Neck Lifts
The distinction between a secondary rhytidectomy
and a revisional rhytidectomy remains poorly defined. In general, a revisional rhytidectomy is one
that is performed to address unsatisfactory results
related to undercorrection or the presence of surgical deformities (▶ Table 14.1).
lifts may be pursued to address undercorrection or
the presence of surgical stigmata such as scar visibility, ear deformities, hairline distortion, or contour irregularities. Prevention is key, as discussed
in Chapter 15’s outline of complications.
Table 14.1 Types of reoperative neck lift procedures
Revisional neck lift Secondary neck lift
Primary neck lift with
unsatisfactory results
Undercorrection
Complications/stigmata
of surgery
5,6
Revisional neck
Primary neck lift with
satisfactory results
Natural aging recurrence
± Complications/stigmata
of surgery
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14.1.2 Secondary Neck Lifts
A secondary rhytidectomy is performed in those
who achieved satisfactory results, but subsequently pursue surgery for age-related recurrence
(▶ Fig. 14.1, ▶ Fig. 14.2).
assessed by evaluating the cervicomental angle, platysmal bands, skin tightness, skin quality, rhytids,
and overall contour. Prior authors have attempted to
investigate the longevity of rejuvenation with variable findings, understandably limited by differences
in operative technique and patient-specific factors.
5,6
Their outcomes are
The subjective nature of a patient’s desire for reope-
ration further complicates this analysis, as well as
individual aging patterns.
7
Consistent objective measures of longevity are
lacking but have included cervicomental angle, surgeon ratings, wrinkle scores, and patient-reported
outcomes (▶ Table 14.2).
7,8
A study by Jones and Lo
suggested that rhytidectomy results are maintained
for approximat e l y 5.5 years, regardless of technique.
However, the neck presents unique challenges as it
relapses earlier than other facial regions such as the
nasolabial folds, marionettes, and jowls.
9,10
Sundine
9
Fig. 14.1 The patient is shown before and after a secondary facelift.
168
14.2 Patient Considerations
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Fig. 14.2 The patient is shown before and after her secondary facelift.
et al’s review of 299 patients undergoing rhytidectomy with superficial musculoaponeurotic system
(SMAS) manipulation found that the average time
to a secondary procedure was 11.9 years.
larly, Guyuron et al found that the average time
was 8.5 years.
4
14.2 Patient Considerations
The patient evaluation for reoperative neck lift
procedures should follow the standard approach
as discussed in previous chapters. Patient goals,
5
Simi-
medical history, physical examination, and photography should proceed systematically. Patients
present at a more advanced age with potential comorbidities. Guyuron et al found that 42% of secondary rhytidectomy patients had acquired a new
medical condition since their primary operation.
They were also more likely to have hypertension
and perioperative blood pressure fluctuations.
Appropriate workup and medical clearance should
be obtained to avoid systemic complications. Patient expectations should be reasonable and psychologic factors should be explored. It is important
4
4
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Table 14.2 Studies reporting longevity of rhytidectomy result s
Study End point Technique Longevity (y) Note
1
Narasimhan et al
Time to SNL Variable 10.3 NL alone
Pelle-Ceravolo
15
et al
Jones and Lo
Guyuron et al
Funk and Adamson
Sundine et al
Friel et al
Abbreviations: FL, facelift; NL, neck lift; SFL, secondary facelift; SNL, secondary neck lift; SR, secondary rhytidectomy.
9
4
5
11
Surgeon rating
platysmal bands
Scoring system Variable < 5.5 FL/NL
Time to SR Unknown 8.5 FL/NL
6
Time to SR Primarily deep plane 9.95 FL/NL
Time to SR Variable 11.9 FL/NL
Patient reported SMAS–platysma lift 68% at 12.6 FL/NL
to note any prior nonsurgical and surgical rejuvenation procedures. Prior operative notes should be
obtained and reviewed.
Complete transection + midline
plication + lateral anchor
14.2.2 Factors Influencing
Longevity and Outcomes
45% < 1 NL alone
Several patient-dependent factors may influence the
14.2.1 Identification of Deformity
The physical examination should assess prior scar
placement and quality. There may be elongation
or tethering of the earlobe in the form of a “pixie
ear.” The tragus of the ear may be obliterated,
tensioned anteriorly (“s hot gun ear deformity” ),
or distor ted.
or ir regu lar. Submental hollowing commonly occurs from excessive fat resection or inadequate
platysmal plication, and it may lend a “cob r a
neck” a ppearance. Horizontal submandibular
bands may be visible at rest or with neck rotation
and are often a result of poor distribution of skin
tension. The ver tical band deformity presents
with a single central skin fold extending from the
submentum. They result from an overzealous midline platysmal plication, inadequate release and
redistribution of the skin envelope, or fibrosis.
Contour irregularities can come in many varieties,
ranging from fat deposits to unnatural soft-tissue
repositioning. The cranial nerve examination
should pay particular attention to any preexisting
paresis or asymmetry. Tissue mobility can be assessed by manually simulating lateral skin displacement. Photographic documentation should
be obtained at rest, with facial animation, and with
neck rotation. All scars should be visible in the
images.
12
Subcutaneous fat may be atrophic
longevity of results. Younger patients or those with
mild-deformity typically have superior outcomes.
The tissue quality is often better in this population,
allowing for more secure repairs and subsequent
soft-tissue contraction.
14
Earlier recurrences are seen
in those with thin skin and less subcutaneous fat.
Those with greater skeletal support, such as those
with prominent cheekbones, chins, and mandibles
tend to maintain their results in the long term.
Alternatively, a more caudal or anteriorly positioned hyoid bone may restrict the degree of improvement in the cervicomental angle.
with a deeper cervicomental angle preoperatively
generally show improved outcomes.
should be counseled to adhere to healthy lifestyles,
reduce sun exposure, and consider maintenance
regimens in the interim.
The rhytidectomy technique associated with the
1
greatest overall longevity remains in question. For
8,10,16
facelifts, a twin study comparing SMAS plication,
SMAS-ectomy, and SMAS flaps resulted in equivalent outcomes.
17
Some report more sustained
results with use of deep plane rhytidectomy.
However, other authors found no difference between SMAS plication and deep plane approaches,
particularly in patients under the age of 70 years.
For neck lifts, failure to plicate midline platysmal
bands may impart suboptimal results. Narasimhan
et al reported earlier recurrence in patients who
8
Patients
8
Patients
8,13
15
8,14
18
19
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14.3 Problem-Based Technical Considerations
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did not undergo an open midline platysmaplasty.
Jacono et al report a deep plane approach that advocates for use of the submental approach when
anterior bands are greater than 2 cm apart, obtaining 1.2 cm of lateral pull per side.
20
Moreover, they
recommend performing an anterior plication
when performing non–deep plane rhytidectomies
and in those with predisposing characteristics,
such as a low hyoid or a short neck.
20
Other authors recommend opening the neck when anterior
bands are less than 2 or 3 cm apart.
21
Pelle-Ceravolo et al’s earlier technique of complete platysmal transection, midline plication,
and lateral anchoring reveale d band recurrence in
45% of patients at 1 year.
15
Guyuron et al showed
no difference in band recurrence with or without
platysmal transection.
22
They found no recurrences in over 26 years with the vest-over-pants
midline platysmaplasty.
22
Clear conclusions are
difficult as most studies are limited by technical
variations, use of concomitant procedures, selection bias, small sample sizes, anatomic al variables, and the subjective nature of evaluation.
17
is generally accepted that a platysmaplasty with
fat contouring provides an acceptable degree of
improvement.
23,24
The surgical approach should
prioritize patient safety, address the anatomical
deformity, and provide consistent results in the
surgeon’s hands.
23
1
14.3 Problem-Based Technical
Considerations
The selection of surgical technique is a multifactorial process that considers the prior operative approach, surgical sequalae, tissue quality, laxity, and
patient preferences (▶ Table 14.3). In general, incisions are placed in the ideal location when sufficient laxity allows for scar excision. Dissection is
typically within the scarred plane, aiming to maximize the subcutaneous fat thickness of the skin
flap. Attenuation of the SMAS in secondary operations should be expected.
6,25
As such, SMAS plication may be favored over sub-SMAS approaches in
these patients.
25
Importantly, skin excision is typically more limited in secondary cases.
ough analysis and operative plan are essential to
correct and prevent deformities (▶ Table 14.4).
14.3.1 Poor Scar Placement
Widened or visible scars are common complaints
It
in patients seeking reoperative neck lifts. In the
presence of clearly adequate skin laxit y, the incisions may be placed in the new ideal location and
the old scars excised. It is generally advisable to
use the old incisions at the start of the procedure
and then resect tissue as able to avoid undue tension on closure or double incision lines.
6,25
3
A thor-
Tertiary
Table 14.3 Technical considerations in the reoperative neck lift
Challenge Recommendations
Skin incision Poorly placed scars
Wide scars
Flap dissection Fibrotic tissue
Less mobility
Displaced structures
Thin tissues
Reduced cross-innervation
SMAS management Attenuated SMAS
Poorly mobile SMAS
Skin excision Inelastic envelope Less skin excision, wider undermining
Adjunctive procedures Fat atrophy
Poor skin quality
Abbreviation: SMAS, superficial musculoaponeurotic system.
Place incision in ideal location if adequate laxity to excise
scars; otherwise, use old scars
Meticulous dissection in or above the same plane
Midline flat fat preservation
Limit dissection if anatomy is obscured
Plane definition may improve after a few centimeters
Often plication over SMAS flaps
Midline platysmaplasty with skin redraping
Partial platysma transection
Fat grafting
Skin resurfacing in areas not undermined
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Table 14.4 Deformities encountered following primary rhytidectomy
Condition Management Options
Poor scar quality Excise scars if sufficient laxity Use old scars, refine closure
Occipital hairline step-off deformity Proper closure alignment
Tragal deformity
Loss of pretragal sulcus, straight
tragus, and “shot gun deformity”
Earlobe deformity “pixie ear”
Ear axis angulation
Submental hollowing “cobra neck” Avoid fat over-resection
Recurrent platysmal bands Identify other etiologies
Vertical band deformity Scar release
Midline ridge deformity Neurotoxin, steroids, massage
Subauricular band deformity Release subauricular membrane
Abbreviation: EAC, external auditory canal.
Proper incision selection
Avoid tension and necrosis
Use pretrichial incision
Thin flap at pretragal sulcus
Triangular flap from excess
Place tension on the mastoid fascia
Deliver lobule last at closure
Lobule pexy
Leaving caudal lobule closure open
Treat lateral subplatysmal fullness
(fat, digastric, gland)
Midline platysmaplasty
Neurotoxin
Wide undermining
Ensure smooth palpation
Rotation/advancement flap
Preserve hair follicles
Suture flap into depression
Release pretragal fascia
Place tension > 2cm above EAC,
superior-posterior to the helix
Wedge excision
Flap readvancement
SMAS to mastoid or conchal anchor
Correct axis
Partial platysmal transection
Skin redraping
Fat grafting
Partial transection
Platysmaplasty
Wide undermining
Midline skin excision
Plication release and redo
Bury knots, avoid overtightening
rhytidectomy patients may present with two sets
of scar lines when the same incision is not utilized
in the secondary case.
2
Treatment involves incising
the more posterior scar and recruiting enough tissue to excise the more anterior scar.
2
Occipital hairline step-off deformities may result
from a malaligned skin closure, substantial skin
excision with prior post-trichial incisions, or from
alopecia secondary to damaged hair follicles.
“2-cm rule” may be applied to identify proper
placement. If more than 2 cm of skin is estimated
to be excised, a pretrichial occipital incision is preferred to prevent superior hairline displacement.
Correction often requires wide undermining and
lateral platysmaplasty to recruit tissue for scar excision. This allows subsequent advancement and
rotation of the flap to realign the hairline, particularly when skin redundancy is more limited.
Similarly, when a concomitant redo facelift is performed, the temporal hairline incision should be
172
analyzed. A new pretrichial incision may be selected if the distance from hairline to orbital rim is
greater than 5 cm, preventing an abnormally wide
cutaneous temple. It may also be selected if the
sideburn is short or obliterated.
12
Beveling the
incision can allow additional camouflage on hair
regrowth through the scar line. Follicular hair
12
transplantation may also be considered.
The
The submental incision may be placed within
26
the natural crease, anterior to the crease, or 1 to
1.5 cm posteriorly.
22,27
The latter placement is gen-
erally preferred as the subcutaneous tissues are
12
thicker, thereby preventing postoperative accentuation and a double-chin deformity.
28
Guyuron et al
advocate for an anteriorly placed incision to aid in
obliteration of the submental crease.
22
If the prior
submental scar is of poor quality, a very cautious
12
resection may be performed. Care must be taken
not to over-resect tissue here as a tethered midline
vertical band along the anterior neck may result.
14.3 Problem-Based Technical Considerations
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14.3.2 Scarred Tissue Planes
Scarred tissue planes should be approached with
caution as critical structures may be repositioned
or more superficial. Although the delay phenomenon may augment the vascularity of the skin
flaps, it should not be relied upon to perform more
aggressive maneuvers. In the absence of prior
nerve injury, dissection within the scarred plane
itself may prevent surgical misadventure. Hydrodissection with tumescent solution can assist in
plane development and hemostasis, even though
the scarred plane is typically less bloody.
24
The dissection will often extend past that of the previous
surgery to obtain adequate mobility.
24
Care should
be taken to maximize preservation of subcutaneous fat, particularly in the midline and postauricular areas. In general, the dissection proceeds with
greater ease after 2 to 3 cm of elevation in the
scarred plane.
One must also consider a potential reduction in
facial nerve cross-innervation from prior asymptomatic transections. Some studies have shown an
increased incidence of facial nerve injury in secondary rhytidectomy with sub-SMAS flaps (11%).
Although no comparative studies have been performed, others report nerve injury incidences similar to primary cases with SMAS-ectomy or SMAS
plication (2%).
29
The SMAS layer may be attenuated, and in the presence of altered anatomy, any
sub-SMAS dissection should be guarded. Overall,
the approach should be consistent with surgeon
experience and comfort level.
6,30
Surgeons should
also anticipate more conservative skin resections
compared to primary cases given reduced tissue
pliability and fibrosis.
29
Funk and Adamson
showed a threefold reduction in SMAS thickness
with revision cases. They also showed an average
skin resection of 17 versus 26 mm in primary rhytidectomies.
6
14.3.3 Platysmal Bands
Recurrent platysmal bands are a common complaint in those presenting for secondary neck lifts,
with an incidence of almost 90% according to some
1
studies.
areas of facial laxity.
skin excess or laxity, as in massive-weight-loss
patients, may be predisposed to early recurrence.
Bands may also become more visible with age, following the atrophy of camouflaging subcutaneous
They tend to recur sooner than other
2,12
Patients with significant
fat. Although recurrence is unavoidable in some,
they may result from poor technique selection, suture failure, accelerated aging, or scarring. Narasimhan et al found that 76% of their secondar y
neck lift patients did not undergo a primary midline platysmaplasty.
1
An accurate diagnosis is key to correct the deformity. The recurrence is typically in the anterior
midline, which may be corrected with a submental
approach and muscle plication.
1
Lateral bands may
be treated with lateral platysma displacement and
muscle suspension. Platysmal bands are classified as
hypertonic, hypotonic, or pseudobands (skin only).
Dynamic bands may be injected with neurotoxin for
short-term improvement. Some advocate partial
platysmal transection for the definitive management of thick hypertonic bands. However, recurrence may still occur due to muscle regeneration,
incomplete transection, or continued contraction.
Complete platysmal transection has been discouraged following observations of linear depressions,
prolonged edema, thyroid cartilage accentuation,
and hematomas.
facial paralysis patients supports the potential
5
utility of muscle dener vation with cer v ical nerve
transection.
1
The absence of neck bands in
31
Yet, concerns remain regarding
variable nerve anatomy , weakness in lip depression,
and laxity of the supportive neck “hammoc k. ”
In the presence of tethered scars or poor tissue
redraping, wide undermining of the skin flap may
be required. Subplatysmal structures may not have
been addressed previously and may require t reatment. The digastric muscles or submandibular
gland may require debulking or suture suspension.
In the presence of a hollowed submentum, the
digastric muscles may be plicated at the midline to
fill the depression. Pre- or subplatysmal fat deposits may also need to be addressed.
27
14.3.4 Midline Ridge Deformity
Patients who have previously undergone midline
platysmaplasty may present with a palpable ridge
of scar, suture, or muscle. The use of a continuous
suture plication, as in the corset platysmaplasty,
may be contributory.
over-pants platysmal plication to prevent this
deformity.
ensure a smooth repair on palpation prior to closure.
1
Suture knots should be buried. The midline ridge
22
With all approaches, it is important to
may require operative release, undermining, and
reclosure.
27
If identified early in the postoperative
22
Guyuron et al utilize a vest-
15
27
32
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course, one can consider massage, neurotoxin injection, or steroid injection.
14.3.5 Submental Hollowing
The submentum may present with an unnatural
depression at rest with increased prominence on
animation, often referred to as the “cobra neck deformity” or “dug out deformity.”
3,12,28
Treatment
involves proper identification of the anatomical
etiology and methodical contouring. Submental
hollowing may be prevented with conservative
preplatysmal fat resection. Appropriate liposuction
techniques should be utilized with the suction
holes directed away from the dermis. When subplatysmal fat is resected, it should not be limited
to the midline alone as the fat pad extends laterally. An untreated prominent digastric muscle or
submandibular gland may also exacerbate the
deformity.
27
Skin tethering should be massaged in
the early phases and steroid injections may also be
considered. Restorative fat grafting may be appropriate in the absence of other anatomical contributions. Reoperation may require wide undermining,
treatment of lateral subplatysmal fat, digastric plication, or midline platysmaplasty.
27
14.3.6 Vertical Band Deformity
Patients may present with a vertical band extending from the submentum to the lower neck, referred to as a “vertical band deformity.” It may be
the result of limited undermining and poor tissue
redrape. Scarring of the skin flap to deeper structures may also alter the tissue redistribution. A
revision neck lift with wide undermining and skin
excision may be adequate. A midline Z pattern skin
resection in male patients may be considered
when skin is particularly redundant.
27
14.3.7 Subauricular Band
Deformity
A prominent vertical or oblique skin fold extending
from behind the ear to the lateral neck has been
described as the “subauricular band deformity.”
results from incomplete release of the vertical subauricular membrane, traveling along the sternocleidomastoid. Correction is achieved by careful release
on skin flap elevation while avoiding injury to the
great auricular nerve.
33
33
14.3.8 Ear Deformity
The tragus and ear lobule may be distorted after
prior rhytidectomy. The pretragal depression may be
obliterated or the tragal edge blunted, often telltale
signs of prior surgery. Cautious defatting anterior to
the tragus may prevent or correct the blunted depression. Some advocate suturing the undersurface
of the flap to the SMAS to highlight the sulcus.
Others release the overlying pretragal fascia and suture it anteriorly to produce a concavity.
tional sculpting of distinct tragal angles, after tissue
mobilization, may restore tragal shape. With pretragal skin deficiency, a new tragus may be fashioned from a triangular flap of redundant skin
superiorly.
4,26
When excessive tension is placed on
the tragal closure, it may be pulled anteriorly creating the “shot gun deformity.”
12
A pretragal incision
is preferred in those with preexisting tragal flexion
or soft tragal cartilage.
3
Tension should be directed
greater than 2 cm cranial to the external auditory
canal, superior and posterior to the helical–temple
junction.
26
Elongation of an attached earlobe, or “pixie
ears,” results from excessive tension on the lobule.
The lobule should not be delivered until the surrounding incisions are closed, with tension directed
toward the superior helix and mastoid. Lobule–
facial flap closure should be loose with zero tension.
Some advocate for division of the SMAS flap and suturing it to the mastoid fascia to support the lobule
position.
3
Others leave the inferior aspect of the lobule closure open to prevent contraction caudally.
Correction can be achieved with mobilization of the
flap and reclosure, wedge excision, or suturing the
flap to the posterior concha.
3
The lobule may also
be suspended superiorly to the SMAS to prevent
inferior migration.
26
14.4 Expert Commentary by
Dr. Lin
My coeditors have outlined the numerous etiologies and treatment of various secondary findings
of the revision face and neck lift patient. While
there is often more than one proposed solution to
It
any individual physical finding, one must first
make an accurate diagnosis of the physical finding
and formulate a plan for the assessed area. Patient
education is paramount to communicate the natural
causes or time frame regarding the need for secondary face and neck lift procedures.
34
3,4
Inten-
12
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