Q: Dr. Eppley, I previously had a mini direct neck excision with a horizontal chin scar and a vertical scar extending about halfway to the Adams apple. I am 54 years old and had this procedure done to deal with loose skin from a previous chin reduction done ten years earlier. Is it possible to update this procedure into more of a direct neck lift? Is it possible to extend the scar a little more vertically to take up some lower neck slack?
A: Since you are already have partial direct necklift scars, there would be no reason why you could not extend the vertical portion lower. The lower end of a direct necklift is very effective at tightening loose skin above the adam’s apple. While it can be technically done, the only issue to be considered is how well the lower end of the direct necklift will do. In younger skin this lower end of the scar may not heal as well as the scars directly under the skin. While the risk of significant hypertrophic scarring from the lower end of the a direct necklift is low, it is a potential issue to be made aware.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in having a direct neck lift and was wondering if i would be a good candidate for the procedure. Also, I was born with a cleft lip. I would like to fill in the hairs on my upper lip to cover the scars. Could you use the redundant neck skin as a source for the donor hairs, since they are facial like the lip or would you use scalp hairs? Thanks.
A: Whether one is a good candidate for a direct necklift is based on the degree of loose neck skin, age and one’s tolerance for a very fine vertical neck scar. The direct necklift tends to be a procedure most commonly done and accepted in men older than age 65…although that does preclude any man younger than that age if they meet all the other qualifications. You are absolutely correct in making the assumption that the neck skin could be the source of donor hairs for transplanting into the cleft lip scar.
Dr. Barry Eppley
Q: Dr. Eppley, here are a few photos of my necklift result. You can see that the results of my traditional neck lift were not bad, just not as well as I hoped for. I do have the lateral scar under my chin and scars behind my ears so my surgeon did tighten my skin. As I mentioned I do have a sharper jaw line and thinner neck but not quite the neck angle I expected. If I place my thumb in the crook of my neck and slightly pull the loose skin to one side, it looks exactly the way I wanted my surgery to turn out. If that can be achieved by a direct neck lift then I would consider that option. Can you tell me what that runs price wise and is it common enough that most surgeons would be adept at that procedure?
A: While I have no idea what you looked like before your traditional necklift, those results look very good to me and are about the best you could have hoped for. Because of potential hairline and beard skin distortions and the heaviness of male facial skin, it is usually not possible to have a very sharp or close to 90 degree neck angle. To have thought otherwise suggests a fundamental misunderstanding in the preoperative consultation/education process.
A direct necklift can make that final change into a sharper neck angle if one has some tolerance for a midline neck scar in the depth of the neck angle area. Whether you would have a favorable scar depends on how tight the skin is in that area. Loose neck skin in the older male when a wattle is present heals remarkably well. Tight skin in a middle-aged male may be at higher risk for hypertrophic scarring.
Dr. Barry Eppley
Q: Dr. Eppley, I am a plastic surgeon in New Mexico and need your thoughts on a facelift patient that I did six months ago. She is a 65 year-old woman that I did a full facelift on. Despite pulling and getting her as tight as I could, she is now left with some loose residual skin in the neck. She nor I want to go through another facelift procedure and I doubt very highly I could get her neck to get any better by this approach. Do you have any suggestions.
A: For residual loose central neck skin after a facelift, one option is either a submentoplasty or a direct neck lift. A direct necklift is always more effective if she is willing to accept a fine line central enck scar. A good direct necklift option for this lady is what I call the Zipper Necklift. It is just a running w-plasty from the submental crease down to a low horizontal neck crease no lower than the thyroid cartilage. (never go as low as into the sternal notch area) By the pictures you can see it is just a running w-plasty excision/closure. The key is the markings. Halfway between the submental and thyroid cartilage pinch the loose skin together and mark it. That will be the point of the widest arc of excision. Then make a vertical ellipse from top to bottom but make the lines INSIDE your previous pinch mark. Then mark your running w-plasties going to the outside of that mark. Excise full thickness skin and fat right down to the platysma muscle. Then you can sew the platysmal muscle together from submental to thyroid cartilage like never before. Close the skin with 4-0 or 5-0 Vicryls for the dermis and 5-0 or 6-0 nylon for the skin. Ointment or glued on tapes is the only dressing. They will have virtually no pain and very minimal swelling and bruising. This will be the sharpest neck angle that you have ever created! The w-plasty concept is to prevent a straight line scar contracture which is greater in women than men because men do a daily scar treatment….shaving. (microdermabrasion)
There are different variations of the direct necklift and the most common is the ‘candelabra’ pattern which adds horizontal excisions at the submental and thyroid cartilage areas. But given that your lady has already had a facelift, she may only need more central neck tissue excision.
Dr. Barry Eppley
Q: Dr. Eppley, I am 44 year-old male interested in a direct neck lift but I think a modified version. My saggy neck skin is caused after neck liposuction when skin did not fully re-attach firmly and/or shrink, so the underlying muscle is fine. I just need the excess sagging skin removed and the neck tightened up. I do NOT want a behind the ear neck lift and like the direct neck lift. Also I like the fact it can be done under local anesthesia.
A: The direct neck lift has the advantage of treating loose neck skin by direct excision and is very effective as a result. But it does so at the price of a scar. This is usually not a big concern in the older male (> 65 years old) who has a classic turkey neck problem but may be more of a potential aesthetic issue in the younger male with less loose neck skin. For this reason I might consider an alternative to a vertical neck skin excision to that of a horizontal excision right under the chin. This is more formally known as a submentoplasty. It removes much less skin than the direct neck lift but has a much better scar camouflage. At your young age, I question the wisdom of vertical neck skin removal and the subsequent scar when the problem is loose neck skin after liposuction. This tells me that the skin redundancy issue is mild and much less than a drooping neck wattle.
Dr. Barry Eppley
Q: I am a male and am interested in the direct neck lift and want to know more about it. I don’t want a complete lift and think this may be my answer. How much of a scar remains visible and will it last a long time. Also, do you tighten the muscles and remove some of the fat?
A: The direct necklift is an alternative to a facelift for a select number of men and women that are interested in getting rid of their neck wattle. A facelift works out excess neck and jowl tissues by chasing them back towards the ears and placing the scars there. A direct necklift cuts out the neck wattle directly, placing the scar right down the middle of the neck. It is a highly effective procedure that produces neck results that are just as good, if not better, than what a facelift can do particularly in men.
In the direct necklift, not only is skin removed but fat and muscle tissues are changed as well. With the skin cutout, the underlying fat is removed as well right down to the muscle. The split platysma muscle is widely exposed with the overlying tissue removed. Because of the excellent visibility, it can be sewn together from under the chin right down to the thyroid cartilage with superb tightening achieved.
The direct necklift is not for everyone but for just a select few patients. In my Indianapolis plastic surgery practice, I reserve it primarily for older men (55 years and older) who either do not want to undergo a facelift or have a very poor hair pattern and density around their ears. The occasional woman is done but they are almost universally 65 years and older and are choosing the direct necklift vs a facelift because of its lower cost.
The obvious issue with a direct necklift is the scar. Generally these scars are quite thin and the only widening that occurs in them is in the middle of the neck where the tension is the highest. For this reason, I usually place a z-plasty scar orientation in this area to avoid hypertrophic scarring there. I have performed no scar revisions on them to date which speaks to patient acceptance of their final aesthetic appearance.
Dr. Barry Eppley
Q: I am interested in the direct neck lift and want to know more about it. I dont want a complete lift and think this may be my answer. How much of a scar remains visable and will it last a long time? Do you tighten the musles and remove some of the fat during the procedure?
A: A low hanging neck, or wattle as it is sometimes unaffectionately called, is a concern for both male and female patients particularly as they get older than 55 or 60 years of age. The traditional and most method of treating these neck concerns is a conventional facelift. In this procedure, the loose neck skin is moved back from the central part of the neck up and backwards and then trimmed off, putting the scar in a near invisible location in and around the ears.
When one doesn’t want to go through a facelift procedure, due to either lack of good hair around the ears or the expense and recovery, the direct necklift may be a reasonable alternative option. Because it cuts the wattle out directly, it leaves a vertical scar running down from under the chin to just below the adam’s apple. Both skin and underlying fat is removed and the platysma muscle is also tightened, which is both easy and very effective due to the wide open exposure. It is a simple operation with very little recovery, minimal swelling and bruising and virtually no pain other than some neck tightness.
The issue is the scar which is why it is not for everyone with a neck wattle, particularly younger patients and most women. It is largely an older male procedure as many men do not have good hairlines and are interested in going through a smaller less drastic procedure. Neck scars in men tend to do fairly well as they have thicker beard skin and do an unintentional but helpful scar treatment daily, known as shaving or microdermabrasion. But for the right older female who has less of a scar concern, it can make a dramatic neck difference.
The scar down the neck can be done several ways, either as a straight line, a straight line with a central Z, or a running w line. (like a pinking shear cut) I have used them all and the choice of which scar pattern is used is based on skin quality and the tightness of the closure. Most scars will become fine white lines that are very acceptable. Scar revision is always possible also but is not commonly needed in my experience.
Dr. Barry Eppley