Your Questions

Q: Dr. Eppley,  I am 49 year old male and in good shape but yet I have a really bad sagging neck. Attached are photos of my neck from the front and both sides.  I’ve always had a sagging neck and had liposuction done 24 years ago so the fat under the neck is not great but the muscle and skin sag.  I’d like a sharper jaw line.  I consulted with a surgeon here who stated that to achieve a sharp jaw line, I’d need a full facelift and that a neck lift alone would only achieve a partial result.  This doctor stated that I should get a facelift and I don’t want a full facelift – I just want the neck tightened up.  Thanks for your time.

A:  Thank you for sending your pictures. The dilemma that you have is a common one for many men. They want to improve their neck and jawline but don’t want the facelift operation to do so. They believe that a ‘necklift’ will solve their concerns. What the plastic surgeon told you was correct…partially. You can only redrape the neck and jowl skin up over the existing jawline through a lower facelift procedure. The concept of a full necklift is really the same as a lower facelift….they are one and the same. There are other neck tightening procedures but they achieve their effects by making changes below the jawline.Thus they tighten but never really truly lift the neck…achieving only the partial result that your plastic surgeon correctly informed you of.

This dilemma leaves you with two options. First an isolated submentoplasty can be done from under the chin which will tighten up the neck angle but will have no effect on making the jawline sharper or more prominent.  (neck angle change) The other approach to augment the jawline with the submentoplasty. This would be particularly beneficial in your case as your jawline/chin is somewhat vertically deficienct. Improving the prominence of the lower jaw through a wraparound jawline implant with a submentoplasty will make the entire jawline stronger, will pick up loose skin in the neck and create a sharper neck angle.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a necklift to get rid of my turkey waddle. What would be the best surgical option to do so? I have attached a side view picture of my neck so you can assess the waddle. What type of recovery would be needed?

A: Thank you for sending your picture. Your turkey neck poses a bit of a challenge given your hairstyle. Normally a more traditional lower facelift (neck-jowl lift) would be the preferred treatment. But with no hair cover around your ears, this makes it challenging for incision placement to get the optimal neck contouring which is needed most in the center of the neck. This leaves us with the alternative option of a direct necklift with a fine line neck scar down the center of the neck between the underside of the chin and the adam’s apple. You situation is actually common in today’s world as so many men now just shave their heads.

A direct necklift has a much simpler recovery than a more traditional lower facelift as the loose neck skin is excised directly rather than being loosened and being shifted to another location (ears) for removal. One can look pretty good in a week after surgery other than a healing neck scar.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank you for taking the time to generate this computer modeling image for me. Although striking, I find the jaw line in the modeling too bold or strong for my liking. Perhaps I need time to acclimatize to the new look. I am more inclined to a long slim straight jaw line with small round (almost but not quite pointy, but not square or large round/oval) chin as in the first attached image.

I understand that you would be making a custom implant from the CT Scan I will provide. But from my limited web research, I have made the following observations. If Implantech implants were used, the back of the jaw would just be built out to appear 1” below the ear as opposed to the modeling of 2” below the ear (using a jaw angle lateral width implant versus an vertical lengthening jaw implant). I understand that the chin implant (such as the vertical lengthening chin by Implantech) would add projection reducing pre jowl sulcus as well as help with the angle under the chin. (See second attached image).

My big concern is with my neck angle in profile. Would a neck lift with removal of playsmal fat banding create a nice sharp neck angle (horizontal as opposed to 45 degree angle)? Would the above mentioned vertical lengthening be appropriate to correcting this problem?

A: The main role of computer imaging is to see what type of changes a patient is looking for. So having thrown that first draft out there, you have provided the direction I was looking for in regards to your jawline shape goals.

When making custom implants, there are different than what standard stock chin and jaw angle implants have to offer. They can be made to any dimensions one desires and would be connected between all three. That is a significant advantage when it comes to addressing any loose skin around the jawline and neck lift as it will pick it up to some degree through a volumizing effect. This effect combined with a small neck lift should address any neck issues and create more of a well defined and sharper cervicomental angle.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, How feasible would it be for a healthy 70-year-old female to undergo a “turkey neck, jowl, eyelid” lift?  I’m on Medicare and a fixed income. 

A: Feasibility for any type of facial rejuvenation procedure(s) (such as a lower facelift and eyelid lifts) is determined by two factors. First, age is really an irrevelant issue as long as one has good health. There are many 70 year old and older patients that very successfully undergo these procedures without any problems. The oldest patient I have ever done for a facial procedure (necklift) was a 92 year-old man! So as long as you are healthy and have laboratory studies which are normal, your age is not a limiting factor for the surgery. Secondly, there is the affordability of the procedure. These are plastic surgery operations not covered by Medicare. As such, they must be paid for as an out of pocket expense up front before the surgery. These costs would be affected by what type of lower necklift and how many eyelids are being done. For most patients at any age, the cost of the surgery is usually the determining factor of feasibility. I would need to see some pictures of your face to determine what the feasibility numbers would be for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a necklift question. I want to know why you can’t just make an incision behind the ears and pull the skin up. When I pul the skin back along my jawline all my wrinkles disappear. This seems like such a simple thing to do so why is a necklift not done this way?

A: You are basically describing how a necklift (lower facelift) is done. There are variations of where the incisions are placed around the ears and whether the deeper tissues are manipulated and tightened . When you use your fingers to create a ‘facelifting’ effect, here is the trick to see where the incisions must be placed. First, the finger traction test must be done right next to the ear not more forward along the jawline as that creates a false result with too much of a change. The fingers must be placed from where the point of pull actually comes from by the ears. Secondly, put your fingers in front of the ear as well as behind the ear and do the lifting. You will see that a far more effective change occurs in both the jowls and neck when the pull is done from the earlobe and upward. This indicates that all effective lower facelifts must have an incision along the front of the ear to create an adequate skin movement. How far the incision goes on the back of the ear is determined by the severity of the neck sagging problem. In short, you can not have an effective lower facelift by an incision limited to just the back of the ear.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am possibly interested in a limited facelift. I am generally taken for younger than my 64 years and have been told by physicians that I have very good skin. But my neck, to me, is hideous. There are some other signs of aging about my face, but in general I can live with those–it’s the neck that upsets me in my mirror view. I assume you do consultations? Are there brochures you could send or websites to recommend? Thank you.

A: While the entire face ages in everyone, many people are most concerned about the changes in their neck as they get older. The neck angle opens up and drops as skin sags, fat accumulation develops and platysmal muscle separation occurs. In women in particular they will often develop wrinkled or creepy skin as well. At age 64 the only good and effective solution is going to come from a lower facelift, often called a necklift or a neck-jowl lift.  This procedure lifts up and redrapes all of the neck skin back up over the jawline and around the ear. In essence, putting the tissues back up from where they came and turning back the clock on how the neck looked 10 to 15 years earlier.

The best way to a consultation with me is to send me some pictures and we can initially talk by phone or Skype. You never have to leave your home to get all the information you need to know!

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I always felt I had too much skin  in my neck and as you can see from my pictures I have no jaw line and I must have too many platysma  muscles causing  me to have this large oversized  neck. I have the neck of a 80 year old and have had this since I was 19. If you look at my high school year picture it is not too bad but for some reason after I hit 20 my skin just got more and more loose in my neck. It just sucked. Which is why I can never wear a hat as all you see is my multiple chins. I hate  the fact that I have this old man neck and have had it all these years. If I gain an ounce its always in my neck and face. Just fyi, I’m 5'10 and 219lbs. My BMI or fat percent when I am training  regularly is 19 which is not bad. But when I slack off it’s between 25 to 30. I really just want too get rid of all  this loose skin and for once in my life be able too wear a hat!!! Does it take long too recover since I am embarassed and don’t want anyone to know. Have you seen this Lifestyle Lift advertisement? Would that help? Thank you so much for looking into this for me, greatful for your time. From a guy with too many chins.

A: The problem is your neck is not just loose skin or 'too much platysma muscle' (such a thing doesn't exist), it is a combination of anatomic factors including loose skin, subplatysmal and supraplaytsmal fat, a high hyoid bone and a mildly recessive chin. The one thing you absolutely don't want to do is the Lifestyle Lift. That would be a waste of money for you because that is an operation that is too small and inadequate for your neck problems. That is really a limited form of a facelift that is good for jowling problems but is inadequate for you neck concerns. What you really need is a neck-jowl lift combined with chin augmentation with aggressive work in the submental/subplatysmal area. (all part of what is more commonly called a facelift) That is the only approach that will have any chance of making a significant change. Do not waste your time or money searching for other solutions that appear simpler and easier…because they will not work for your anatomic neck problem.

When you look at recovery from this type of operation, it is going to take two or three weeks to look pretty good again and you feel comfortable out in public. So it is a commitment on your part to make this change. Yours is not a neck problem that will be fine in a few days or a week after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 55 year old women who is a little overweight. At 5’4” and 190 lbs, I wouldn’t call myself fat just above my ideal body weight. The reality is that this weight is very stable and have been relatively the same weight for almost 20 years. I exercise and eat reasonably and this is just the way it is. I am fine with that as I am otherwise healthy.  My face has always been al little plump but otherwise firm until the past few years. I have noticed that there is some jowling that has appeared along the jawline but the real problem is my neck. It has gone to hell in the proverbial hand basket. It has gotten so droopy and saggy that I know it is time for some type of necklift. My question is am I too fat to get any benefit from such a procedure?

A: Your question is a good one and would be a lot more relevant when you were younger. But as you have gotten older, enough though it sounds like you have a rounder fuller face, the skin in the neck has begun sag. This sagging is the result of the skin stretching and loosening, no longer being able to support the weight of the fat it contains. While I would have to see pictures of your neck to be certain, many females with similar situations and face shapes actually get great benefit from neck reduction/tightening. Until proven otherwise, it may be that you may get a greater benefit from a necklift than someone who is thinner with less loose skin. It would make sense to delay your facelift if you were planning on losing weight but that clearly is not the case.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 38 year-old woman and am bothered by the amount of skin under my chin. I would like a more youthful and tightened neck look. I have read about lot of different neck rejuvenating procedures such as a necklift and a ‘trampoline’ neck lift. the necklift/facelift seems like it is too much for my problem while the reviews I have read on the trampoline lift do not give me much confidence. What would be the best procedure for my sagging neck skin?

A: There are a variety of neck tightening procedures as you have mentioned. In the array of neck improvement options, they have differing effects on neck rejuvenation depending upon what they are designed to treat. Given your relatively young age, it is hard to imagine that you have enough loose skin to warrant the maximal tightening procedure of a full necklift. It may be that simple liposuction, particularly Smartlipo or laser liposuction, may create enough of a skin tightening effect. This  would depend on whether you also have enough fat in the neck to warrant it. A so-called trampoline necklift achieves its skin tightening effect from liposuction. The sutures placed are designed to create a sharper cervicomental neck angle not to tighten the skin. A more simplified version of this procedure is the standard submentoplasty where sutures are placed to tighten the platysma muscle above the thyroid cartilage and liposuction is used to reduce fat and tighten skin. I would really have to see pictures of your neck to determine what may be of best benefit to you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to improve my profile. I am 53 years old and have always had a round face. But as I have gotten older and gained weight, it has gotten more so. About 20 years ago I had a chin implant placed. It helped a little but the result was not what I was looking for but I have lived with it. Now I would like to rejuvenate myself a little bit and get my jawline looking better. I have attached front and side pictures for your recommendations.

A: Thank you for your inquiry and sending your photos. In looking at them, you have chosen the correct procedures, neck recontouring and chin augmentation. The chin augmentation is straight forward. A forward projecting chin implant of 8mm to 9mms would give much improved augmentation.  This is in addition to the chin implant you already have. I suspect it is a very small inplant that is likely placed too high on the bone. So I would remove it and replace it with one that is bigger, more square-shaped and positioned lower on the bone. Your very full neck (bullfrog neck deformity) is the challenging procedure. This can be approached from three different approaches; liposuction only, liposuction with submentoplasty or a full necklift. I think with your size neck and excess skin that only a full necklift will give you the maximal improvement. Males with thick necks never get as much tightening and cervicomental angle creation as females so the most aggressive approach needs to be done. I have attached a side imaging profile to show what I consider to be a conservative result, meaning the least amount of improvement that I would expect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have had Restylane and Juvederm injections infrequently over the past 6 years. Two different Dermatologists did them. However even though my results were exceptional at times, the most recent Juvederm treatment seemed lumpy and inappropriately placed. I am hoping a surgeon might have a better result with better knowledge of where the product should be applied. Also, I was wondering about whether very slight eye injections to soften laugh/smile lines would be available? I am 65 years old look 40. I had a mini-facelift 24 years ago and it was the best decision I ever made. Now, however, I would like to also consider a Lifestyle Lift if possible. Less of course is more in the long run, although I am noticing a slight  sag under the chin now. Possibly Juvederm or Restylane can smooth that with out changing my facial features. My hope would be to have this all completed in one or two visits as soon as possible.  I would like to be treated on first visit as I am very busy with work.

A: While injectable fillers can make some wonderful facial changes, they are not useful for every facial aging problem. They are of little value in the crow’s feet or periorbital line areas as these are very superficial wrinkles. Injections of crow’s feet have a high incidence of irregularities and lumpiness. This is usuallya better area for Botox and fractional laser resurfacing. But it would depend also on how deep the smile lines are. Also injectable fillers will not be able to smooth out loose skin under the chin. This would be better treated by some type of a face or necklift.

Dr. Barry Eppley

Indianapolis, Indiana

The thought of eating turkey at the upcoming Thanksgiving holiday brings together two inseparable images. While history does not show that turkey was ever actually served at the first pilgrim’s festival, it has become the featured culinary dish since. While many will enjoy the tasteful bites from a turkey leg, breast or stuffing, few will aspire to have the turkey neck.

While few want to eat a turkey’s neck, even fewer want to have one on of their own.  The turkey neck or neck wattle is that well known fleshy fold of hanging skin that is unavoidable for many as we age. The loss of a once smooth jaw line and a shapely neck shows the persistent effects of gravity and time.

While creams and other potions promise much, the turkey neck needs a surgical fix. Forget about non-surgical options and other ‘lunchtime’ type procedures. They simply do not work no matter how hopeful one is. For the fuller neck in a young person, fat removal by liposuction alone may be enough. But when the neck skin is loose and floppy, and you can pinch a wad of skin and fat between your fingers, some method of actual removal is needed.

The removal of a turkeyneck requires some form of a facelift. While often misunderstood, a facelift is really a neck and jowl operation and does not change the face much above the level of one’s mouth. It is a poorly named procedure and the term necklift would more accurately describe it. It is really less extensive and easier to go through than most people think.

When it comes to necklifts, there are numerous options.Which one is best for any particular person is determined by how much loose neck skin one has. Some jowling and a little loose neck skin may only need a limited facelift. If there is a lot of loose neck skin, then a fuller form of a facelift is really needed. This is a powerful neck changer and can produce some really dramatic results. For those that want the least invasive amount of surgery but with a dramatic change, the turkeyneck can also be directly cut out in a procedure appropriately called the direct necklift.

The turkeyneck is not a desired culinary item on the bird and many people don’t like it on themselves either. While year round turtlenecks are always an option, a little skillful carving may be a better solution.

Dr. Barry Eppley

Indianapolis, Indiana

Catching a glance in the mirror or looking at a picture and seeing those sagging jowls and a droopy neck can be a troubling finding. It often seems like it came out of nowhere. I have yet to see a person find this discovery charming. While hope lies in that some magic cream or laser treatment will make it all go away, deep down inside we all know it isn’t true. (but we can dream can’t we?)

When it comes to that loose jowl and neck skin, everyone wants to avoid the dreaded word…facelift. While most people are unaware that a facelift is really just a necklift, everyone would agree that they would like as little surgery as possible. While the fears and recovery surrounding a necklift are largely overstated, one really hopes that they can get by with a ‘minimal’ procedure. This understandable apprehension has led to the nationwide branded selling of facelift surgery.

The best example is that of the Lifestyle Lift. Through their national magazine and television ads, this is a franchise approach to getting a facelift…or some version of it. I have seen many patients who know the name, but don’t really know what it is. Promising to turn the clock back at least ten years and look recovered in just a few days, its catchy name seeks to assure patients that it will fit into their ‘lifestyle’. Interestingly, and perhaps not an oversight, nowhere in their advertising does it even suggest that it is real surgery. Many prospective patients only become aware that it is surgery when they actually visit a company facility.

What is a Lifestyle Lift? While sounding new, it is really quite old and has been practiced by plastic surgeons for decades. It is a scaled-down version of a facelift, a ‘mini-facelift’ if you will.  Sometimes called a tuck-up facelift, a secondary facelift, or a jowl lift, it is a limited operation that best improves those sagging jowls with a little tightening of the neck. The operative word here is a ‘little tightening of the neck’. If you have a neck wattle or turkey neck, this is not the right procedure for you.

Because it has an appealing name, the Lifestyle Lift has created a number of name knock-offs, including the Swiftlift and even the Lunchtime Lift to name just a few. Most of these are surgeons who have jumped on the naming and marketing bandwagon and have given their version of a limited facelift its own name. There is no real difference in the procedure or in whom it is or is not most beneficial.

Because it is heavily marketed and the internet exists, the Lifestyle Lift has its share of critics.  Much of this has to do with trying to make an individualized custom operation into a factory line retail product. As an operation, however, limited types of facelifts do have a valuable role in facial rejuvenation. Not every patient needs or wants a full facelift.

Facelifting is not an operation that should performed the same on everyone. Nor does having a catchy name mean it leads to better results or a quicker recovery. Many plastic surgeons offer similar limited types of  facelifts that just don’t have a branded name, but that doesn’t make them any less effective or useful.

Dr. Barry Eppley

Indianapolis

Q:   I am 52 years old and have myasthenia gravis. I had a thymectomy 23 years ago and currently have very minimal symptoms. I am interested in reducing the appearance of aging, especially in the neck and jowls. Is the IGuide or another minimally invasive procedure recommended for patients who have myasthenis gravis? If not, what are my options to improve my appearance?

A: Having the condition of myasthenis gravis (MG) poses potential issues for anesthesia for surgery but not for the surgery itself. You are likely interested in minimally invasive facial surgery because of its often association with local anesthesia and potential avoidance of general anesthesia. What you want to avoid with any form of anesthesia is a myasthenic crisis. This occurs when the muscles that control breathing weaken to the point that ventilation is inadequate, creating a medical emergency and requiring a respirator for assisted ventilation. This is most likely to occur in those MG individuals whose respiratory muscles are weak. This does not appear to an issue for you whose has minimal symptoms. Nonetheless, it is best to avoid any form of general anesthesia particularly for elective cosmetic surgery.

The IGuide neck procedure, a more limited type of necklift (e.g., Lifestyle Lift) or both done together are procedures which are effective in individuals with early to moderate neck aging issues. Whether any of these are good procedures for your neck and jowl concerns can only be determined by doing an assessment of some photographs.  They can be very successfully performed under local anesthesia supplemented by either oral or light intravenous sedation.

Dr. Barry Eppley

Indianapolis, Indiana

The shape and profile of the neck, even though it is not on the face per se, imparts an impression as to one’s appearance. Whether one is young with a fat neck or older with loose skin or a turkeyneck, a poorly defined neck angle results. While liposuction can remove fat and a necklift can tighten skin, an ideal neck angle is not always achieved.

What is missing from any cosmetic neck operation is a method to tighten the underlying muscles and tissues. By making a more firm ‘hammock’ that extends from ear to ear, the neck angle can be changed significantly.  A new device, called the iGuide, has now become available to help create a firmer and more youthful neckline.

The iGuide is an FDA-approved device that is for tightening and lifting of neck tissues. It provides a less invasive technique to improve the neck and jawline with minimal incisions (unlike a traditional facelift) while at the same time shortening recovery time. By not doing wide undermining and elevation of neck skin, the swelling and bruising is much less and one’s recovery is quicker.

The iGuide allows the deeper tissue in the neck to be tightened by essentially creating a ‘neck hammock’ using a permanent suture. Through a series of needle punctures placed along the jawline, a suture is weaved back and forth from side to side to create a trampoline-like structure. This suture weave creates a low-tension support which elevates the tissues below the neck skin, a missing element from current necklifting procedures. This type of suture is not to be confused with the infamous barbed sutures (Threadlift operation) of the past.

From a neck recontouring standpoint, the iGuide has multiple potential uses. For the younger patient with a fuller neck where liposuction alone is not completely satisfactory, a suture weave can provide additional neck angle improvement. For the early signs of neck and jowl aging, a short scar facelift is great for the jowl area but may not always optimally treat the neck angle. The trampoline effect of the suture weave makes for a better neck angle result. Older patients with a turkeyneck may still require a more traditional necklift however.

The iGuide neck contouring system, in some cases, may be able to be done under local anesthesia without going to sleep.  If all one’s neck needs is some liposuction and a suture weave, this would certainly be possible. Neither the tiny incisions nor the weaving of the suture requires the use of any sharp needles. But when other facial procedures are being done with it, then more than local anesthesia would be needed.

The iGuide provides a clever minimally invasive approach to redefining one’s neckline and is a great adjunct to liposuction and any form of a necklift.  As its tagline states, it is ‘The Neck’s Big Thing‘.

Dr. Barry Eppley

Indianapolis, Indiana

Turkey and Thanksgiving go together like no other holiday and food combination. While there is no evidence that it was ever actually served at the first pilgrim’s festival, it became a mainstay shortly thereafter. While many will anxiously await for their share of the turkey this holiday, whether it is a leg, breast or stuffing, no one aspires for the turkey neck.

This fleshy fold of hanging skin, known as the neck wattle in the bird, appears in people as well. While in turkeys it occurs mainly in the male, in humans the turkey neck is not gender specific. As we age, the appearance of one’s neck often becomes a bothersome issue. The loss of a once smooth jaw line and a shapely neck shows the effects of gravity and time. Catching one’s profile in a picture can sometimes be disturbing…who is that older person with such a floppy neck?

While creams and other potions do much to alleviate’s one’s pocketbook, the turkeyneck is otherwise a surgical problem. Forget about non-invasive options or ‘lunchtime’ type procedures. These simply will not work for the dangling neck no matter how they are marketed or hopeful one is. For the full neck with good skin, and if one is young enough, good results can be had with liposuction alone. But when the skin is loose and floppy, fat removal alone with only make the neck skin more loose and floppy.

If you can grab a wad of neck skin and fat between your fingers, then some form of a facelift procedure is what is needed. Using the term facelift can be confusing as this procedure often conjures up images of extensive surgery from the forehead down to the neck. In reality, a facelift is really a neck and jowl operation and does not affect the face above the jaw line. It is a poorly named procedure and the term necklift would more accurately describe it than calling it a facelift. It is really less extensive and easier to go through than most people actually think.

When it comes to facelifts (aka necklifts), there are numerous options.Which one is best for any particular person is determined by how much loose neck skin one has. Some jowling and a little loose neck skin may only need a limited facelift. (often called the Lifestyle Lift) If there is a lot of loose neck skin, then the more complete facelift is really needed. This is a powerful neck changer and can produce some really dramatic results. For those that want the least invasive amount of surgery but with a dramatic change, the turkeyneck can be directly cut out in a procedure appropriately called the direct necklift.

The turkeyneck is not a desired culinary item on the bird and many people don’t like it on themselves either. While year round turtlenecks are always an option, a little skillful carving may be a better solution.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am 5’7″ and weigh 128 lbs. Even though I am relatively thin, I have always had a double chin for some reason. But I feel like it has gotten worse since I have given birth to two children and have gained over 40 lbs with each pregnancy.  I am interested in knowing what could be done and how much improvement I could expect. Getting rid of this double chin would help me feel more confident. Thank you so much for your time.

A: The cause of a  ‘double chin’ is a combination of three anatomic factors; neck fat, neck skin, and chin projection/prominence. Every double chin is made up of differing ratios of all three components. It is always about how much neck fat is there, how much extra neck skin there is, and how short one’s chin may be. While you didn’t state your age, that number also has an influence because it suggests how much neck skin you may have and, most importantly, how elastic it is.

Some double chins can be corrected by as simple a procedure as neck liposuction in someone who is young and with decent chin projection. On the flip side, an ‘older’ severe double chin may require everything including neck liposuction, chin augmentation, and some form of a necklift to help tighten the extra loose skin. Each patient must be assessed individually and a custom treatment plan devised as double chin correction is not a one size fits all procedure.

One surprising aspect to the ideal correction of double chin problems is that of the chin. Many people have short chins that are magnified by this problem. Lengthening the jawline with a chin implant while bringing the angle of the neck back (or making it more defined) is the classic ‘ying and yang’ approach which together makes a better result than either change alone.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am 65 years old and am extremely bothered by my turkey wattle. I do not look my age except this makes me very self conscious. I want to get rid of it with some type of neck procedure. What do you recommend?

A: Sagging or drooping of one’s neck is one of the most bothersome features of facial aging. While some people would never consider undergoing a ‘facelift’, they want some type of neck procedure to deal with their most troublesome age-related issue.

Aging necks are referred to many uncomplimentary names such as turkey neck and neck wattle. Some people become initially aware of it when they see themselves in profile in a photograph. Others notice it, particularly men, when wearing certain shirts and certainly in a shirt and tie. Others do not like, understandably, that it can be felt to move or flop when turning their head. (in more advanced aging)

Interestingly, some people would consider a necklift but wouldn’t dare undergo a facelift. This comes from a misunderstanding of the two procedures, not realizing that they are largely one and the same.  I have found only a handful of patients in my Indianapolis plastic surgery practice who actually knew what a facelift really was.

A facelift is primarily a necklift. The type of facelift determines how much improvement in the neck is obtained. A limited facelift (aka Lifestyle Lift) has a minor effect on neck sagging and is best for just minor neck problems. It is primarily a jowl changing procedure. A full facelift is a powperful changer of the aging neck. The differerence between the two is the location and extent of the incisions around the ears. To really change the neck in more significant wattles and sagging, the facelift must have an incision that goes up behind the ear and back into the occipital scalp. It is the pull from behind the ear that changes the neck. You can demonstrate this quite simply with your fingers in front of a mirror. A manuever that many patients with aging faces have done regularly.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr Eppley I have had my lower eye bags and lids done and also had a MAC facelift with liposuction to my neck all at the same time. I now have two eyelids that are different and am not pleased with the result of my lower neck. I went back to see the surgeons yesterday and they said they would have to do the two eyelids again but can’t do the neck any better. I am 65 years old and after reading your article about a low horizontal neck lift I wonder if this is would nto work for me. That procedure has given me hope but I can’t trust my previous surgeons to do it.

A: The MAC facelift, like all forms of limited facelifting, is a great procedure for the right patient. The right patient for it is one that doesn’t have a significant neck problem or a lot of loose neck skin. These limited facelifts are primarily jowl reducing/smoothing procedures with some minor improvements in the neck area. Those improvements are helped through the use of neck liposuction, but the key to getting a good result is that the neck skin must not be too loose.

When one has a more significant neck issue, a full or more traditional facelift procedure is more appriopriate. This is a much more powerful neck procedure. One of the problems with these limited facelifts is that they get used in patients that really should have had a more complete necklifting procedure. As a result, they can often be disappointed with the neck result. I suspect this is what has occurred in your case.

Once can always have a secondary more complete facelift done to improve your neck result. Having had a MAC facelift does not preclude that. Saying that ‘no more can be done’ suggests to me that they are either unwilling or incapable of doing a more complete facelift procedure.

A low horizontal neck lift is always an option and certainly is simpler and easier than reverting to a complete facelift. As long as one can accept a fine line scar in a low neck crease, this could be an option worth considering. That could even be done local anesthesia.  

Dr. Barry Eppley

In running across a copy of Nora Ephram’s best selling book by the same title, I could not help but think how many times I have heard this very phrase from patients. While we are long past Thanksgiving,  some may still be thinking of turkey in a different light…that of their ‘turkey neck’.

Many people want to improve the appearance of their neck without having to resort to a facelift. Getting rid of a neck wattle would return them to a younger look and be able to wear ties, turtlenecks or jewelry more comfortably. The fear of a facelift is a near universal one. Whether one feels that they are too young or too old for surgery, do not have time for any significant recovery or cannot afford it, many potential patients are drawn to any procedure or method that offers an alternative.

Some fuller necks or neck wattles may benefit from targeted treatment just to the neck. Such neck rejuvenation, known as submentoplasty, only works on the neck removing fat and tightening muscles. No incisions are around the ears are needed unlike traditional facelift surgery.

As we age, definition and smoothness under the chin and along the jaw line is lost. This occurs due to fatty deposits, weakening muscles and the appearance of loose skin. This results in the obliteration of a sharp neck angle, where the neck and chin meet. Often this just becomes a straight line angling obliquely down from the chin to the lower neck.

Neck skin is different from the rest of facial skin. It generally has much more elasticity and can actually contract or shrink upward after being released from the underlying muscle and fat. Given that the neck skin lies on the underside of the chin, many would think that it would fall downward and hang more after being released. But this does not generally occur unless one’s neck skin is paper thin.

The submentoplasty procedure is done through an incision under the chin. First, fat removal in the neck is done with liposuction. This is followed by midline platysmal tightening and wide freeing of the neck skin from the muscle. Whether liposuction alone or the complete submentoplasty procedure is needed will depending on the age of the patient and the quality and amount of loose neck skin that is present.

Younger patients (less than age 35), who generally have more skin elasticity and have a skin wattle because of too much fat underneath the skin, usually just need liposuction only. Middle-aged patients (ages 35 to 55) have fat deposits also but in addition have a loose or split plastysmal neck muscle and skin. This requires the full submentoplasty method of treatment. Older patients (age 55 and over) almost always need extensive neck recontouring and a facelift is needed where loose skin is actually removed.

In my Indianapolis plastic surgery experience, I have found that adequate neck rejuvenation for many patients requires some version of a facelift. But age is a key factor in determining the suitability of a submentoplasty. In patients under age forty-five, about half of them can get good results with a submentoplasty and avoid a facelift. Over the age of forty-five, however, that number drops to less than one in ten. And over the age of fifty-five that numbers drops to essentially zero.

While submentoplasties are a primary treatment for certain neck issues, it can also be used as a secondary tuck-up after a facelift. Some facelifts, particularly with really saggy necks, will often get some rebound relaxation in the submental region which is furtherest from the point of skin pull way back at the ears. A submentoplasty allows further neck refinement when the results of the facelift begin to relax.

Dr. Barry Eppley

The plastic surgery treatment of the aging face often involves a facelifting surgery. A facelift is one of the top ten cosmetic procedures performed in the United States. Despite its frequent performance and its recognition by the public, it is a procedure that is usually misunderstood.

The most common misconception of a facelift is that it does very little for much of the face. It is a procedure that has its impact on the neck and jowl areas. The rest of the face is untouched by the operation. While other procedures are often done with it, such as eyes and brows, these procedures are not part of the a traditional facelift operation. A facelift should more properly be called a necklift or a neck-jowl lift.

Another misconception about facelifts is what is actually lifted. Everyone understands that face and neck skin is lifted and moved back, but what goes on underneath the skin layer is a frequent point of misinterpretation. Patients often ask me if I am going to lift and tighten the ‘muscles’. From an anatomic standpoint, lifting the facial muscles is an impossibility. Most facial muscles are attached tightly to the underlying bone and moving them would not only be very difficult but would not have any postive benefit. There is only one muscle that is often tightened in a facelift and that is the platysma muscle in the neck, which is often separated due to aging. It is never lifted per se but it is tightened in the middle, from the chin down to the adam’s apple, to help sharpen the neck angle.

The layer underneath the skin that patients misinterpret as muscle being moved is actually a different tissue altogether. Between the skin and the muscles is a layer of tissue known as the SMAS. This is an acronym for a more anatomic name but for simplicity of understanding think of the SMAS as another layer of skin underneath. This layer can be raised up off the muscles and resuspended up higher on the face. The combination of SMAS and skin tightening together generally makes for a better facelift result that may last somewhat longer. 

There is great controversy in plastic surgery about how to most effectively deal with the SMAS during the facelift operation. Many facelift surgeons tout their own techniques and may even have their own names for their ‘type’ of facelift based on their version of SMAS manipulation. While SMAS management in any form of a facelift is a plus, there is no proven superior method of what to do with it. If one single SMAS facelift technique was genuinely best, we all would be using it.

In a facelift, the underlying tissues that are manipulated is the SMAS layer not muscles. SMAS tightening does usually make for a better facelift result that is more durable. However, time and aging will eventually outlast any facelift result no matter how it is done. And the overall goal for most patients is to ultimately outlive their facelift result….or at least I would think so.

Dr. Barry Eppley