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2.3 Neck Rejuvenation Procedures
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Table 2.1 Overview of surgical treatment options based on patient anatomical characteristics
Procedure Incision
Liposuction Access incisions ++ + + + +
Submental
rhytidectomy
Short scar
rhytidectomy
Full scar
rhytidectomy
location
Submental + + + + + + + +
Retroauricular + + + + + + + +
Periauricular + + + + + + + +
Apart from the aforementioned points, the literature revealed similar results in these techniques.
No other clear benefit to set one apart from the
other was found.
36
On the other hand, RFAL is a
relatively newer subtype of liposuction.
devices similarly to the lone radiofrequency device
described earlier in this chapter cause additional
soft-tissue/skin contraction. Interestingly, a recent
study compared the first- and second-generation
37
RFAL.
The first-generation group exhibited 8.3%
minor complications, while the second-generation
group exhibited 0.7% minor complications.
Some data from the second-generation RFAL de-
Skin excess Skin elasticity Fat excess
None Apparent Real Good Poor Subcutaneous Subplatysmal
from 158 to 124 degrees.
31
Additionally, if concomitant facial rejuvenation is planned, liposuction is a useful adjunct. Indeed, the fat can be
37
These
harvested during the liposuction and used for fat
grafting.
37
Due to the nature of the procedure, patients consuming large amounts of tobacco, on anticoagulant therapy, and with significantly elevated
blood pressure are usually contraindicated.
Liposuctions still have risks. These include bleeding,
hematoma formation, swelling, infection, dimpling,
poor scar formation, contour irregularities, and
37
deeper structure damage.
vice revealed a statistically significant reduction
in the overall complication rates compared with
the first-generation device and are worth further
investigation.
37
Regardless of the device used, procedures can be
done under local or general anaesthesia.
29
They all
entail tumescent anesthesia of the subcutaneous
neck and submental fat.
31
Following this, access incisions are performed. The submental and infraauricular are among the most common.
35
Once
these incisions are made, percutaneous tunnelling
of the liposuction cannula is performed. It is important to note that one should avoid excessive,
superficial passes with the liposuction cannula
and not over-resecting the subcutaneous fat in order to prevent complications.
In the neck region, patients with an obtuse cervicomental angle due to submental fat mostly in
the preplatysmal plane with good skin quality
are good surgical candidates. The use of liposu ction remains a gold standard therapy for these
patients.
36
Recently, authors were able to achieve
a mean reduction of the cervicomental angle
Submental Anterior Neck Lift
General Approach
The neck is placed in extension and local anesthesia is infiltrated.
of local anesthesia or tumescent solution can
assist in hemostatic dissection of the tissue. An
incision is performed just posterior to the submental c rease, after whi ch it is released anteriorly from underlying tissues. The dissection can
be performed forward and laterally to notably
release the mandibular ligaments. Following this
dissection, the skin must be u ndermined as much
as needed in order to visualize and address the
platysmal bands. Dissection is further carried laterally as far as needed to expose the platysma.
While preplatysmal adiposity can be targeted
with liposuction prior to the neck lift, direct defatting of the subcutaneous tissue may be ca utiously performed under direct vision as part of
the neck lift. Deeper subplatysmal fat can then be
treated with this anterior a pproach.
38,39,40,41
The administration
29,31,34
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Technical Considerations
The various structures previously described in this
chapter should now be reevaluated and careful
consideration of the state of these structures and
effects on the overall neck structure must be
38,39,40,41
made.
The subplatysmal fat is the first of the anatomical characteristics that can be targeted for treatment. The subplat ysmal adipose tissue lies within
the midline of the neck and extends to some degree toward the submandibular gland. In order to
reach this adipose tissue, the medial border of the
platysma should be elevated, and the fat excised
deep to the platysma. It is important to note that
the surgeon should keep in mind the pitfall of removing excessive adipose tissue. It is vital for an
adequate subcutaneous layer of fat to be preserved
in order to prevent submental depression. The platysma is then repositioned, and sutures are applied to prevent the platysma from dehiscing due
to an unstable closure.
Digastric muscle excision is also a possibility,
but rarely done, in some patients. Following subplatysmal fat excision, it can be exposed via a submental incision. The anterior belly of the digastric
is then evaluated. Depending on the patient characteristics, it can then be tangentially excised,
totally excised, or plicated.
Following the excision/retraction of the anterior
digastric, the submandibular gland can be entirely
visualized. It is important to note that prior to
removal of the gland, the neck should be flexed to
assess the neck contour. If an intervention is
warranted, multiple approaches may be taken. A
partial resection can be performed. The excision
involves an Allis clamp that is used to grasp the
gland, and then a needle tip cautery is used to partial excision. A drain may be placed if the gland is
excised in order to prevent salivary accumulation,
which may require drainage. One should note that
even partial gland excision may result in a salivary
gland fistula and nerve injury. Suspension suture
to the mandibular border or transcervical suspension can also be placed if a minimal prolapse of the
gland not warranting excision is present.
41
Subtypes of Neck Lift
Endoscopic Neck Lift
The first subtype of anterior neck lift is an endoscopic neck lift.
scopic visualization. It is performed via a 3- to 4-cm
42
This procedure provides endo-
submental incision and 1-cm retroauricular incisions with the aid of fiberoptic visualization using a
lighted retractor. However, it is important to note
that this procedure is now rarely performed.
Short Scar Neck Lift
The second subtype of neck lift is the short scar
neck lift.
procedure to correct neck jowling, ideally in a
patient with minimal or moderate skin.
to best address the characteristics of the patient.
One may use a vertical vector on the superficial
musculoaponeurotic system (SMAS) as well as a
diagonal vector on the skin to improve the jawline
and neck. Additionally, the neck can also be contoured using one of the liposuction devices previously described.
through a prehairline and a preauricular incision
ending at the earlobe. After this, a subcutaneous
skin flap is created and then extended to the posterior border of the sternocleidomastoid muscle.
An SMAS platysma flap is then dissected and drawn
vertically in the face and posteriorly in the neck.
Alternatively, a SMAS ectomy or SMAS plication can
be performed through this limited incision. One
should note that permanent sutures are to be used
for the plication or fixation of the SMAS–platysmal
flap. Finally, excess skin is trimmed and tailored,
after which it is directly pulled upward with a diagonal vector posteriorly.
12,38,39,43,44
A few technical variances of this procedure exist
The facial portion of the procedure is done
Patients are indicated for this
Full Scar Neck Lift
Comprehensive Approach
The third subtype of a neck lift is the full scar neck
12,38,39,45,46
lift.
have several reasons. These include the aging
changes of the face and neck, ill-defined neck–face
interface, excess skin, and/or excess skin laxity.
Additionally, these also include static platysmal
bands and visible submandibular gland.
Similarly to the short scar neck lift, a full scar
neck lift has multiple technical variances depending on the patient. In significantly lax skin with
substantial excess in the neck, the retroauricular incision is continued along the hairline to remove the
additional excess skin. The initial key aspect prior
to the removal of the excess skin is to align the hairline. After this, the retroauricular sulcus must be
closed with a three-point suture technique. This
Patients indicated for this procedure
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2.3 Neck Rejuvenation Procedures
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will incorporate the deep fascia in order to prevent
scar migration. Further details on the facelift approach are discussed later in the book.
Skin Flap Procedures
In a youthful nec k, a vertical vector of pull is presen t.
In order to recreate this natural vector in a neck lift,
a posterior and diagonal vector has to be created
when using the retroauricular approach.
46,47
In a neck lift, managing the skin is different from
that of the facial skin. If skin excess is present and
warrant excision, a retroauricular or hairline incision can be considered. In patients with considerable anterior neck redundancy such as following
massive weight loss, skin should be removed using
a direct approach. In these cases, a T-Z incision can
be used when targeting the contour to the cervical
47
angle.
The initial procedure is done through a
midcervical skin excision through which preplatysmal and subplatysmal fat is excised and then
closed in the midline.
Platysmal Procedures
Once platysma diastasis is addressed, the surrounding skin is recruited in the midline.
medial tightening leaves skin tethered laterally to
the attachments of the lateral platysmal fascia,
which provides a generally stronger anchorage. The
skin is then allowed to contract or is excised laterally through a facelift approach. Awide array of specific methods for treating the platysma have been
described.
These include the following:
●
Platysma flap cervical rhytidoplasty. In this procedure, a sectional myotomy of the medial edge
of the platysma is performed in order to enable
a lateral rotation and advancement of the flap
edges. Following this, sut uring of the flaps to
the mastoid fascia laterally prevents recurrence
of the vertical banding.
●
Suspension sutures. Suspension sutures can aid
in the definition of the jawline. They are placed
along the inferior border of the mandible over
the superficial fascia. Sutures are interlocked at
the midline and tacked to the mastoid fascia.
●
Facial and neck rejuvenation with absorbable
polydioxanone is a popular technique in Korea.
A recent study in 2017 in a population sample
of 33 patients showed outcomes consistent with
a low incidence of complications and high rate
of patient satisfaction (94.3%).
tion resolved without surgical intervention, but
39,40,48,49,50,51
48
The complica-
This
some asymmetry was present in some of the
patients.
48
Ultimately, this procedure, which is
indicated in patients with moderate-degree laxity, was shown to be a safe and effective treatment modality within the Asian population.
●
Platysmal muscle sling. In a platysmal muscle
sling, the sling is made by dividing the platysma
horizontally across the entire width. The tissue
then clusters on the cephalad portion of the platysma. This creates a phenomenon known as
the window shading effect.
●
Corset platysmaplasty. For this procedure, a submental incision is performed for an anterior approach, followed by skin elevation. The medial
edges of the platysma are then infolded with a
permanent suture. The neck skin is shifted posteriorly, while the platysmal pull is anterior and
toward the midline. It is precisely this anterior
pull that defines the corset platysmaplasty. The
excess neck skin can then be either excised or
allowed to contract. Occasionally, a very low 3to 4-cm transection from the medial edge
allows comfortable rotation of the muscle flaps
to the midline for multilayered approximation.
A multilayered seam approximates the full
height of the midline platysma muscle edges,
creating a “waistline” to the neck from an anterior platysmal shift. The plication of the muscle
then continues medially to three fingerbreadths
above the suprasternal notch. This is a highly effective and popular technique for recontouring
the submental area. If combined with lateral
plication, midline plication of the platysma can
define the jawline and neck–jaw transition successfully.
●
Hyo neck lift. The Hyo neck lift is a new technique in neck rejuvenation introduced by Claude
Le Louarn, a French surgeon in 2016.
involves a horizontal suturing of the platysma
toward the hyoid and then to the skin to recreate a youthful cervicomandibular angle. The
Hyo neck lift was described as a less invasive
technique that showed improvement in the
contour and flattening of the submental area.
Since then, Claude Le Louarn proposed a major
change to the initial technique of the Hyo neck
lift. He has suggested performing a vertical anterior subplat ysmal and subplatysmal adipose
tissue dissection. This anterior dissection would
ensure a precise fixation of the platysma to the
deep cervical fascia, thus enabling the creation
of a horizontal and posterior vector of tension.
49,50
48
It
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Additionally, the posterior border of the anterior platysmal flap is suspended to the mastoid
fascia. Since the first 10 patients in 2016, 15 patients have undergone a new technique of neck
lift with fixation of the platysma to the deep
cervical fascia and suspension of the lateral
platysma.
50
Challenges and Complications
A certain proportion of postoperative problems
tend to be the result of inappropriate patient evaluation leading to suboptimal choice of surgical
procedures.
cially in thin patients, may be the result of an
overzealous treatment of the subcutaneous and
subplatysmal fat. Inadequate redraping of the skin
because of inadequate undermining or poor skin
quality is an issue encountered by some plastic
surgeons. Undercorrection of the jowls, the jawline, and the neck–face interface can also occur
sometimes. Ultimately, revision with a facelift may
often be required to correct the above issues.
Significant tension laterally to the retroauricular sulcus may also increase the risk of skin necrosis. Forward planning should occur when complications
occur in order to prevent the occurrence of subsequent complications. Indeed, hematoma or infection, especially in the retroauricular area, is usually
followed by skin slough.
Fat Interface Problems
The adipose layers may be either over- or undertreated. Overtreatment usually occurs in the subcutaneous plane, while undertreatment is often
seen in the subplatysmal plane and adjacent to
the submental incisions. Overtreatment can be
avoided by preserving 3 to 5 mm of subcutaneous
fat. This may be facilitated by using smallercaliber cannulas an d limiting passes of sucti on in
the same locations.
Platysma
The remaining or appearance of new plat ysmal
bands is one of the most common complications of
platysmal procedures. These usually occur secondary to suture failure or surgical dehiscence. When
these complications occur, correction is frequently
required. It then necessitates a revision surgery
where the procedure is reproduced, or new/additional resection is needed.
12
Notably, contour irregularities, espe-
Submandibular Gland
Bulging in the submental triangle may occur postoperatively. This is usually from an enlarged gland,
which now protrudes due to thinner or weaker
superficial tissues. Reoperation may be needed.
Digastric Muscle
As previously discussed, excess preplatysmal fat
removal may unmask the digastric muscle. Similarly to the submandibular gland, issues with the
digastric muscle are often seen as a persistent
bulge along the submental area. In these cases,
excision of the muscle bellies may be warranted.
Inappropriate Vectors
Vector planning is a mandatory step in any successful neck lift procedure. Failure to thoroughly
take this step into account may result in poor retroauricular or anterior tragal scars. This is especially true in patients with significant neck skin
excess. One should be careful not to cause excessive traction in any vector. This could result in
banding or bulging the neck area. Revision surgery
may be required to correct vectors.
Postoperative Care
Postoperative care is as important as good planning in ensuring a prompt recovery and good
results regardless of the procedure.
medications may be given postoperatively. Analgesia control is routine, and is usually supplemented
with sleeping pills, and antiemetics. Patients
should be instructed to minimalize any straining
of the neck, and flexion of the neck should also be
avoided. Strenuous activity is restricted until week
6 postoperatively.
In indicated patients, drains are used to eliminate
serum and a small amount of blood. They potentially
reduce postoperative edema and surgeons should
not shy away from using them. The drains can be removed on postopera tiv e day 1 after careful examination of the patient neck.
Dressings and an elastic garment should be applied over the neck and left in place overnight to
absorb any fluid. Operative dressings are replaced
with a neck strap for ≤ 4 weeks. When applying
these, the surgeon or nurse should ensure that no
excess pressure is applied in order to avoid pressure necrosis. The wounds should be cleaned with
half-strength hydrogen peroxide and coated with
12
A variety of
20
References
https://t.me/medicina_free
a topical antibiotic as needed. All nonabsorbable
skin sutures are removed by days 7 to 14.
2.4 Conclusion
Ultimately, one may conclude that many advancements have been seen in the field of neck rejuvenation over the last decades. A careful evaluation
of the patient is paramount in guiding the aesthetic surgeon to select the best intervention for a
patient population that keeps growing in diversity
and complexity. Patients with very little excess
skin but an excess of submental fat, when preplatysmal, can now undergo a wide array of effective
and safe nonsurgical procedures. Patients with
excess skin or platysmal banding should undergo a
surgical approach tailored to their characteristics. To
conclude, as neck rejuvenation grows in popularity,
aesthetic surgeons have the chance to personalize
treatment for their patients to ensure exceptional
results while minimizing complications.
2.5 Expert Commentary by
Dr. Slavin
This chapter provides a thorough review for clinicians on an approach to patients with aesthetic
dissatisfaction of their neck. It reviews each anatomical contributor to neck contours and, moreover, introduces nonsurgical techniques to the
reader. These nonsurgical techniques are an evergrowing category of techniques that are important
for patients and surgeons alike. For patients who
either are not surgical candidates or choose to
forego surgery, knowledge of these devices will be
of utmost importance going forward.
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3 Management of the Aging Neck
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Munique Maia and Alan Matarasso
Abstract
Multiple treatments are available for neck rejuvenation, ranging from medical grade skincare and
nonsurgical treatments to surgical neck lift. In contrast to the face, however, nonsurgical rejuvenation of the neck provides limited improvement.
This chapter discusses patient selection, neck lift
procedures in isolation and in combination with
facial procedures, as well as complications and
their management.
Keywords: neck lift, aging neck, liposuction, submentalplasty, platysmaplasty
Key Points
●
Preoperative analysis and a comprehensive
rejuvenation plan are necessary for optimal
results.
●
Surgical neck rejuvenation can be performed
in combination or independently with facial
procedures.
●
Surgical procedures address the three most important soft-tissue components of the aging neck
(fat, skin, and muscle). Procedures range from
liposuction and submentalplasty to neck lift.
3.1 Introduction
It is a common concept in the general population
that the appearance of the neck can be a sign of
aging and can appear more aged than the face
itself. Characteristics of a youthful neck include distinct mandibular border with the relative absence of
jowls, subhyoid depression, visible thyroid cartilage
bulge, distinct border to the sternocleidomastoid
(SCM) muscle, and a cervicomental angle between
105 and 120 degrees.
in the neck as early as the late 30 s. Consequently,
neck lift was ranked as the 12th most common cosmetic procedure by the American Society for Aesthetic Plastic Surgery in the United States in 2019.
Moreover, that number is greater when including
facelift surgery, which routinely incorporates the
neck. Methods for rejuvenation of the neck include
surgical (extended neck lift, neck lift, liposuction,
and submentalplasty) and nonsurgical (botulinum
1,2,3,4
Aging signs can be present
toxin, deoxycholic acid, dermal fillers, threading,
energy-based treatments, and resurfacing). A comprehensive analysis of the neck is paramount for the
surgeon to choose the correct treatment for each
patient.
Evaluating and determining which components
of the aging neck are contributing to its appearance is necessary to plan treatment. Neck lift can
be performed alone or in combination with a facelift or other facial or body contouring procedures.
Patients often present with a combination of poor
skin quality, excess skin laxity, excess fat, and hypertrophied and attenuation of the platysma and
retaining ligaments. Furthermore, ptotic submandibular gland and digastric muscle hypertrophy
can also contribute to the aging neck. Detailed
analysis of the area will determine if the patient is
a candidate for a surgical procedure and the extent
of the procedure. An algorithm for treatment of
the neck is described in this chapter (▶ Table 3.1).
3.2 Patient Analysis
Aging components of the neck should be individually analyzed and addressed accordingly (Box 3.1).
Systematic examination of the neck from superficial to deep is helpful. Evaluation begins with the
assessment of skin quality and skin quality. The
excess skin of the neck is ameliorated with a neck
lift; however, very little is derived from this in
Table 3.1 Decision analysis and patient education in
treating soft-tissue components in the aging neck
a
Fat Muscle
+ No laxity Adequate Liposuction
+ + Adequate Submentalplasty
+/− + + Neck lift
Note: The three most important soft-tissue compo-
5
nents of the neck (skin, fat, and muscle) represent the
framework for analyzing a range of neck deformities.
a
Platysma muscle: visible or lax medial border platysma
bands (submentalplasty) muscle treatments include
resection, plication (Eiffel tower), or incising.
b
Neck lift often includes submentalplasty.
Skin Treatment
b
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Management of the Aging Neck
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patients with poor skin quality. Poor skin quality
requires skin care and ancillary procedures, such
as lasers, peels, microneedling, fat grafting, or
energy-based devices. This is an important topic of
discussion as it can cause dissatisfaction postoperatively if the patient is not clear on the distinction
and about the goals of the surgery. Next, the presence of platysmal bands should be evaluated in
repose and with muscle contraction. The subcutaneous fat (superficial fat) and subplatysmal and
interdigastric fat (deep fat) are assessed. Contouring of excess adipose tissue with liposuction or
direct excision should be considered. The overall
assessment of the neck and lower face and analysis
of facial proportions should also be performed.
Digastric muscle hypertrophy, submandibular
gland descent or hypertrophy, bony def iciency of
the chin and mandible, jawline contour, and lower
face descent should all be analyzed and can be
treated with appropriate procedures. If the patient
also has concerns about his or her face, additional
procedures such as facelift, chin implant placement, skin treatments, or buccal fat excision
should be discussed.
Box 3.1 Related Components to
Correct Neck Aging
●
Submandibular glands.
●
Jowls.
●
Marionette lines.
●
Hypertrophic earlobes.
●
Microgenia.
●
Buccal lipodystrophy.
●
●
●
1
Larynx.
Masseter muscle hypertrophy.
Parotid gland enlargement.
3.3 Patient Selection and
Preoperative Planning
A successful outcome is essentially a satisfied patient. Consequently, during the consultation, understanding of patient’s concerns and expectations is
paramount. The discussion should also include the
treatment plan and what can be achieved with surgery alone, where the incisions would be placed,
costs, recovery period, and possible complications.
To the extent foreseeable, the limitations and goals
1
Potentially addressed in conjunction with neck surgery.
of each alternative treatments and ancillary procedures should be discussed.
Once the assessment of the neck is completed a
treatment plan is outlined. The treatment options
follow a laddered approach. Liposuction of the neck
is a straightforward procedure and is generally indicated for younger patients with excess subcutaneous fat and good skin elasticity. Although the neck
can exhibit a surprising ability to contract even with
advanced age, submentalplasty surgery addresses
midline muscle laxity and excess fat with some skin
rearrangement, albeit without excision. A full neck
lift addresses all three soft-tissue layers of skin,
muscle, and fat.
7
An extended neck lift that incorporates an additional short preauricular incision can
be considered if the patient desires to address the
lower face and jowl area, which is the transition
area between facial and neck surgery. This is particularly common in patients concerned with jowling
as this extends above the border of the mandible
and an extended neck lift will improve this area
also. Patients can be interested in less invasive pro-
6
cedures; therefore, it is of paramount importance to
educate patients about their anatomy and cause for
aesthetic dissatisfaction. A “downstaged” procedure
that minimizes incision length, discomfort, recovery,
or cost yields a different result than a more invasive
plan. The treatment plan should proceed only after
patient’s expectations are fully understood and they
accept the treatment proposed.
3.4 Operative Procedure
3.4.1 Surgical Technique
The neck lift is performed in an accredited ambulatory operating room under systemic anesthesia
administered by a board-certified anesthesiolo-
8,9
gist.
The incisions are marked and wetting solution (1 mL 1:1,000 epinephrine an d 100 mL 1%
lidocaine in 200 mL of normal saline) is injected
in the field. Th e ear canal is gently packed with a
cotton ball soaked in betadine. One gram of intravenous tranexamic acid is used 30 minutes preoperatively unless contraindicated . Liposuction is
performed first as indicated. A 2.4-mm Mercedes
cannula is used for neck liposuction and a 1.8-mm
Mercedes cannula is used for jowl liposuction. A
spatula tip cannula can be used for additional contour in heavy fatty necks. ▶ Video 3.1
When submentalplasty is indicated (i.e., for midline platysma surgery or deep structure contouring), a 5-cm submental incision is made, just caudal
24
Video 3.1 Neck lift. This video shows injection, sub-
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mentalplasty, medial and lateral platysmaplasty, skin
redraping, and closure.
or cephalic (in this case, it is undermined) to the
submental skin crease. Some surgeons advocate for
a slightly curvilinear incision to account for redraping of the skin in cases of full face and neck lift. The
midline neck is widely dissected and undermined
with the aid of a lighted retractor. Particular attention should be paid to undermining adjacent to the
incision and contouring any fat in this area. Medial
platysma bands are then identified. When redundant medial platysma muscle is present, a strip of
excess muscle can be excised. Conservative subplatysmal fat removal is performed, if necessary, by
either direct excision or melting with ball-tip electrocautery. While deep fat can be safely contoured,
if removed, digastric excision and subm andibular
gland removal should be considered.
10,11,12
Aback
cut (myotomy) is made from medial to lateral in
the platysma at the le vel of the cricoid to treat
hard dynamic band s. In order to stave off reattachment of the muscle fibers, some surgeons
advocate for partial myectomy. If the muscle can
be reapproximated in the midline (based on the
extent of separation), it is done with interrupted
3–0 Mersilene sutures (Ethicon, San Lorenzo,
Puerto Rico) to achieve a snug, but not tight, approximation. Different techniques for platysmal
repair have been described.
13
The hyoid fascia can
be incorporated into the repair with the intention
of avoiding recurrent banding.
14
The submental
portal is inspected for hemostasis and packed
with moist gauze until final inspection and closure after the lateral incisions are closed.
The patient’s head is turned to the left and the
right-side neck lift incision is performed. The skin
flap is widely undermined (usually contiguously
with the area undermined via submental access).
3.5 Postoperative Care
This dissection proceeds and is completed under
direct vision with the scalpel and facelift scissors.
The lateral border of the platysma (and lower
superficial musculoaponeurotic system [SMAS] in
extended neck lifts) is identified. If laxity is
present, the lateral border of the platysma is
undermined and sutured to the SCM fascia, avoiding undue tension on the midline platysmal repair.
In extended neck lifts, the platysma and lower
SMAS are plicated to the SCM fascia at three to
four points to address jowl laxity. Excess skin is
redraped, released as necessary from underlying
attachments, and excised. The earlobe should be
delivered prior to final skin flap excision to avoid a
pixie earlobe. The wound is irrigated with the
same solution used to infiltrate the skin. Final hemostasis is achieved; a drain (flushed with and
soaked in betadine) is inserted, brought through
the incision line, and the incision is closed. Careful
attention is paid to ensure that while redraping and
securing the skin, the hairline is preserved. Hairbearing skin is closed with staples. The region between the hair-bearing skin and the postauricular
incision is closed with half-buried absorbable mattress sutures. The postauricular crease is closed
with 3–0 nylon. The preauricular area (extended
neck lift) is closed with 5–0 nylon sutures. The
closed-suction drain is placed in the postauricular
incision and secured with a suture. The head is
turned to the right, and the left-side neck lift is performed with a similar technique. The submental
dissection is then inspected for final hemostasis
and closed with running subcuticular 4–0 Prolene
and simple 5–0 nylon sutures.
3.5 Postoperative Care
Antibiotic ointment is applied to all incisions and
around the drains. A facelift dressing consisting of
three layers of gauze strips covered with a Surginet
is placed (Dermapac, Shelton, CT). The dressings
are removed on postoperative day 1, and a neck
strap is used. Drains are removed as indicated by
volume and color over the first few days. The incisions are kept moist with antibiotic ointment during the healing process. The sutures and staples
are removed as indicated during the first 10 postoperative days.
The patient is specifically instructed to avoid neck
flexion to minimize the risk of skin flap ischemia
and edema (S. Fredricks, personal communication).
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Management of the Aging Neck
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Patients are additionally counseled to refrain from
any heavy lifting or strenuous activity for the first
2weeksandtoslowlyreturntonormallevelsofactivity over the third through fourth postoperative
weeks. Sun exposure and any topical therapies (facials, peels, etc.) are to be avoided for 2 to 3 months.
Laser removal of facial hair similarly cannot be performed for a few months before and after surgery.
Telangiectasias and postoperative bruising can be
treated with V beam laser therapy in the immediate
postoperative period. Patients should be inspected
frequently for fluid collections, skin ischemia, or
other healing issues. Firm subcutaneous areas may
be apparent during recovery and can be gently massaged, injected with intralesional steroids, or treated
with ultrasound.
3.6 Complications
Complications can vary depending on the extent of
the procedure that is performed. Most frequent
complications include hematoma and seroma. Seromas should be treated aggressively, and patients
should be examined frequently because seromas
tend to reoccur. Treatments include frequent aspiration and compression. Small hematomas can be
treated in the office settin g or emergency room
without return to the operating room (OR).
sterile environm ent, postauricular sutures are removed, the area is irrigated with sterile cold saline mixed with local anesthetic and epinephrine,
and the blood is suctioned from under the flap.
Large hematomas should be treated emergently
in the OR. Our protocol for this is to s uck out the
blood and remove suture prior to scrubbing. Then
the wound is widely opened, inspected, and hemostasis obtained. Rarely, but if indicated, fibrin
sealant can be used and the area ir rigated before
drains are placed. Evidence has consistently supported an appropriate nontraumatic emergence
from anesthesia and a controlled postoper ative
blood pressure (BP) ideal ly below 130 mm Hg in
avoiding a hematoma. Appropriate hypertensive,
anti-anxiolytic, antiemetic or pain medi cations,
andlaxativesareadministeredasneededto
prevent spikes or elevation in bl ood pressure.
Although skin necrosis is infrequent, it can be a
significant complication when it occurs. We use
dimethyl sulfoxide (DMSO)
ointment for these issues. Facial nerve injuries
16
and nitroglycerin
15
In a
are less common than in facelifts but can occur.
Most often, the marginal mandibular branch and
the cer vical branch are placed at risk during the
procedure if the overlying platysma muscle is
breached. This is more frequent in secondary
surgery particularly when midline surgery is
performed. It has a tendency to occur when defatting just lateral to the sub mental incision caudal to the mandibl e. T he majority of injuries will
resolve in 6 months to 1 year. Injury to the great
auricular nerve is the most common nerve injury
in neck lift procedures. Careful attention is advisedwhendissectinginthelateralneckareain
the region of McKinney’spoint.
Deep vein thrombosis (DVT) and pulmonary
embolism (PE) are rare in neck lift surgeries. A
study in 2001 showed 0.35% DVT and 0.14% PE in
9,937 facelift procedures. Given the low incidence
of DVT and higher risk of postoperative bleeding
(16.2%) in patients treated with low-molecularweight heparin,
mittent compression devices are recommended, as
is early ambulation.
Infection in neck lift is also relatively infrequent.
Preoperativel y patients use Hibiclens soap and hair
wash, intranasal mupirocin ointment, and oral antibiotics if needed. Intraoperative intravenous antibiotics, wound irrigation, and packing the external
auditory canal with betadine-soaked cotton plugs
are done. Infections tend to appear later, that is, 6 to
10 days postoperatively, manifested by fluid collection and erythema, and less ecchymosis than would
be seen with a hematoma. Wounds should be
cultured (including for methicillin-resistant Staphy-
lococcus aureus [MRSA] and broad-spectrum antibiotics coverage instituted until sensitivities return),
copiously irrigated, drained, and broad-spectrum
antibiotics used for an appropriate length of treatment. The patient should be monitored frequently
and drained percutaneously as needed.
18,19
it is not used; however, inter-
17
3.7 Ancillary Procedures and
Nonsurgical Treatments
Treatments to improve skin quality are important
adjuncts for optimizing outcomes. Photoaging,
perioral wrinkling, and dyschromia are treated in a
staged manner with chemical peel or laser resurfacing. These procedures are safe and cost-effective
26
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