The Thick Neck: To Open or Not to Open

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Every facelift or neck lift procedure I perform at my Toronto plastic surgery practice is different. It is the job of an experienced plastic surgeon to adopt his or her technique to the patient’s anatomy, skin quality, muscle and/or skin laxity, hairline pattern, expected progression of hair loss, history with smoking, time commitment to recovery versus maintenance with fillers, and so on.

A common issue that I encounter when performing a facelift or neck lift is the thick neck. As a plastic surgeon, I believe one has to open the anterior neck to properly address all its components.

Here is my comprehensive approach to neck rejuvenation through facelift or neck lift:

1. A thick neck can be solely the manifestation of excess superficial fat which can be taken care of with liposuction, assuming the fat is superficial to the thin neck muscle called platysma. If the fat is very central, BELKYRA™ can be used, an in-office injection treatment.

2. In several cases of thick neck, there is also a significant component of fat beneath the platysma which can only be resected carefully under direct vision, paying attention to the neck veins and to the submandibular glands.

3. A thick neck can also be associated with swollen submandibular glands and lymph nodes. Moreover, a thorough neck liposuction can unmask a sagging submandibular gland, making the facelift and neck lift result sub-optimal. Submandibular glands can sag and/or can be hypertrophied or swollen. Various options exist to tackle this issue and I will discuss this in a future blog post.

4. Another maneuver to restore the angle is to either release some tight neck fascia (perihyoid) that blunts the neck-jaw angle or in other situations, the harvesting neck fascia can be tightened to reduce slightly the neck circumference and slimming the appearance of the neck.

5. The conservative resection of the digastric muscles is yet another option. This involves 2 small muscles close to the mid line, that can contribute to residual fullness post-operatively and a suboptimal neck lift result. If the muscles are not hypertrophied, I sometimes perform multiple transverse cuts to weaken them up and gain length to restore the neck-jaw angle. Widely-separated digastric muscles should be approximated with sutures as to prevent a depression in the central neck, something also seen with over-resection of deep fat in the neck.

6. Some thick necks are made to look thick by unusually large (and often sagging) jowls, and even repositioning them with the facelift will not correct the heaviness of the lower face: A careful resection of a small amount of fat, under direct vision, can be performed, either from the anterior neck or posterior cheek approach when doing a facelift.

7. The last key component is the lateral pull when performing the facelift, the so-called SMAS lift. Securing both the right and the left neck’s SMAS’s to the back of the ears act as a hammock and will contribute significantly to a young-looking sharp neck.

There is complexity, art, and technique to neck lift procedures, just as much as there is with facelift surgery. Unfortunately, the neck is often forgotten entirely or done mechanically without a comprehensive approach. I truly believe a well-performed neck lift is key to a successful facial rejuvenation.

Until next time,

Dr. DuPéré

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