Key points

Introduction

One of the most common complaints of the cosmetic patient is the neck region. Excessive skin, muscle laxity, and increased fatty deposition are all factors that lead to an unwanted aging effect. Nevertheless, the esthetic improvement of the anterior neck complex remains one of the most challenging aspects of facial rejuvenation. This area is often one of the first places people complain of during the “aging” process: whether it is an early accumulation of unwanted fatty deposition, an increased prominence of platysma banding, decreased definition in the cervicomental angle, or loss of skin-muscle tone. There are several combinations of these complaints among a wide variety of ages ( Fig. 1 ). It is important to understand what the patients’ primary concerns are and which proposed treatment would give a maximum outcome. It is also important to have an artistic eye and predict the patient’s outcome for their desired procedures to ensure that the other local facial structures will not hamper treatment results.

Note the difference in neck structural types. Patient on the left exhibits mild submental lipomatosis, whereas the patient on the right has redundant tissue, lipomatosis, and banding. Also, note the second patient has much more prominent jowls and mandible notching.

Preoperative understanding of the patient’s desired outcome is paramount in selecting the appropriate surgery. Younger patients that still possess good skin elasticity may be able to have a simple liposculpture procedure, whereas an older patient having the same procedure may not be as pleased with the outcome due to unmasked jowling that is now more apparent or possibly the insufficient intrinsic contractility of skin. Complete fat removal in neck tissue does not lend itself to the optimal result ( Fig. 2 ). An understanding of the patient’s current anatomic state will then most commonly dictate what type of procedure will be performed. These procedures can range from simple liposculpture, to direct lipectomy, platysmaplasty, or complete cervicoplasty encompassing a combined facelift ( Box 1 ).

This patient had prior neck liposuction. The result was oversculpture and now a more visualized platysma band ( arrow ).

Introduction

One of the most common complaints of the cosmetic patient is the neck region. Excessive skin, muscle laxity, and increased fatty deposition are all factors that lead to an unwanted aging effect. Nevertheless, the esthetic improvement of the anterior neck complex remains one of the most challenging aspects of facial rejuvenation. This area is often one of the first places people complain of during the “aging” process: whether it is an early accumulation of unwanted fatty deposition, an increased prominence of platysma banding, decreased definition in the cervicomental angle, or loss of skin-muscle tone. There are several combinations of these complaints among a wide variety of ages ( Fig. 1 ). It is important to understand what the patients’ primary concerns are and which proposed treatment would give a maximum outcome. It is also important to have an artistic eye and predict the patient’s outcome for their desired procedures to ensure that the other local facial structures will not hamper treatment results.

Note the difference in neck structural types. Patient on the left exhibits mild submental lipomatosis, whereas the patient on the right has redundant tissue, lipomatosis, and banding. Also, note the second patient has much more prominent jowls and mandible notching.

Preoperative understanding of the patient’s desired outcome is paramount in selecting the appropriate surgery. Younger patients that still possess good skin elasticity may be able to have a simple liposculpture procedure, whereas an older patient having the same procedure may not be as pleased with the outcome due to unmasked jowling that is now more apparent or possibly the insufficient intrinsic contractility of skin. Complete fat removal in neck tissue does not lend itself to the optimal result ( Fig. 2 ). An understanding of the patient’s current anatomic state will then most commonly dictate what type of procedure will be performed. These procedures can range from simple liposculpture, to direct lipectomy, platysmaplasty, or complete cervicoplasty encompassing a combined facelift ( Box 1 ).

This patient had prior neck liposuction. The result was oversculpture and now a more visualized platysma band ( arrow ).

Effects on aging/variability of neck types

The anterior neck region is more of a sweeping topographic landscape with smooth undulations versus its more flat upper facial counterparts. A youthful-appearing facial and neck region has a smooth textured appearance, well-defined cervicomental angle, and appropriate suspended fullness. Ellenbogen has long established the visual aspects of a youthful neck appearance. A youthful neck appearance has been classified as having a cervicomental angle between 105 and 120° with a distinct mandibular border and smooth nonbanded overlying skin draping ( Fig. 3 ). However, as our aging process begins, the initial tone and texture of the more superficial structures is the first visible structure change. Further substructural changes within muscle then give way. It is this laxity of suspensory neck muscles in combination of increased fatty deposits and inferior gravitational movement of the patient’s jowls that account for aging of the neck region. Furthermore, the accumulation of excessive fat deposits is increased with aging, weight gain, and certain medical conditions. Several classification systems have been introduced to characterize this process. I have adapted the Baker classification system, as its 4 subtypes seem to encompass most of my patients’ aging attributes ( Box 2 , Fig. 4 ).

Note the youthful, smooth neck contour and acceptable chin neck angle.

Note neck classification types A–D.

In addition, there other components that this author thinks can potentiate this aging appearance over time, such as submandibular gland ptosis and mandibular bony atrophy—both of which contribute to a poor cervicomental angle and loss of volume. They can further pose some difficulties to the surgeon, as the decision needs to be made in regards to which procedure or procedures should be performed to maximize outcome and achieve the highest success with the patient’s expectations.

Patient expectations

In evaluating the patient’s anterior neck region, several factors come into play. First and foremost is the patient’s biggest concern, their chief complaint. In my presurgical consultations, I always explain to the patient that we both must see their issue—if I cannot, this becomes a flag to me, or if I see something that the patient does not complain of, I will point it out, because I can see a potential issue that may become exacerbated in the future if the wrong surgery is performed.

In listening to my patients, I often hear that they do not want anything too invasive or they only want a few days of down time or they do not want a facelift, just fix their sagging neck. Well, as I like to explain to my patients, there is the “right answer” for their problem and then there is the “right procedure” for their problem. What I mean by this is, for example, if a 60-year-old patient comes into my office and wants his/her neck “tightened” and his/her eyes “lifted”—what he/she likely needs is a brow lift, upper/lower eyelid lift, full face/neck lift, laser resurfacing, and possibly chin and cheek implants. They need 2 to 3 weeks of downtime to achieve this simple complaint. Explaining this to a patient that liposuction and a blepharoplasty will not provide an optimal outcome on her/him (like it did on a 40-year-old friend) can be difficult. Therefore, even though the optimal procedure for this type of patient would be a more classic complete facial rejuvenation, I may tailor the surgery to meet my patient’s more specific requests. I am not advocating a “quick-fix procedure,” but think it is very important to keep all of the patient’s expectations in mind to the best of my abilities. At this point, I may recommend staged surgeries or give the patient a complete understanding of why the “quicker” procedure would not be most beneficial for her/him ( Figs. 5 and 6 ).

This younger male patient was able to achieve a very good cosmetic result—liposculpture with a chin implant with minimal downtime.

This older female patient requested “liposuction” to her neck; after careful discussion, it was deemed that a combined facelift and cervicoplasty would be needed to achieve her expectations along with a 2-week downtime period.

Indications for neck rejuvenation

Given the complexity and variability of the anterior neck region, most treatment options will be individualized for each patient. Age, gender, race, social history, habits, and genetics all play major roles in the aging process. Table 1 provides a brief description of the problem areas and their respective treatments and is a basic guide for what would be necessary to correct the problem. Often it is the combination of 2 or more of these procedures that is necessary to maximize outcomes. An in-depth description of neck subregions is described later in this article.

Table 1

Problem areas and treatments

Problem Area	Treatment
1. Subcutaneous fat	Liposculpture or direct lipectomy—age dependent
2. Excessive skin	Direct excision with redraping (isolated neck/or facelift)
3. Subplatysma fat	Direct excision with platysma tightening
4. Platysma bands	Platysma plication with inferior back cut
5. Retrogenia	Alloplastic implant or orthognathic surgery
6. Poor neck angle	Combinations of all the above

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