Your Questions
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 double chin correction. Attached you will find some pictures that I took–today during my lunch break! Looking at me straight on, at a flattering angle, you can tell I have a round face but the double chin isn’t noticeable. When I smile widely, laugh, or am viewed from my profile, it is clearly evident. What are my treatment options? Will liposuction alone work as another doctor told me? Let me know your thoughts!
A: Thank you for sending your pictures. While there is certainly some subcutaneous fat to liposuction, that will give you a modest improvement only. Necks like yours almost always have a subplatysmal collection of fat in the midline that will not be changed by liposuction. This requires a submentoplasty technique to maximally tighten the neck angle. You also have a bit of a horizontally short rounder chin. This adds a third factor to the double chin appearance. Adding a small central button style chin implant will add a little more horizontal projection and change the frontal chin shape to more of a tapered chin look.
In conclusion, it is all about the degree of double chin correction you are seeking.Liposuction alone will produce a modest improvement, a submentoplasty (which includes neck liposuction) will make a good change and the final addition of a chin implant will make the best overall double chin correction. As you can see neck liposuction is the most basic approach but does not produce the best double chin correction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a minor amount of loose skin under my chin and between my Adam’s Apple that I want flattened. The neck skin has very little, if any, fat. I’m 51 years old and my skin heals from cuts and abrasions very well. The procedure with the lowest trauma and shortest recovery time along with the lowest cost is preferred. Please let me know what procedure you recommend, along with the its recovery time to where I can be out without the procedure being noticeable. Thank you.
A: Thank you for sending the pictures and describing your objectives. The small midline neck wattle poses a bit of a quandary in terms of an ideal procedure. It is not big enough to justify any more major surgery (formal neck lift) but it is significant enough that is it not going too respond to smaller minimally invasive procedures. (e.g., external skin tightening, liposuction etc) Thus in these situations one is ‘forced’ to choose a procedure that is not perfect. (can not create the ideal result or has some trade-offs) This translates into either a submentoplasty with liposuction (otherwise known as a submental tuck up or a direct small neck lift. (most effective since the skin excess is vertical but the scar may not be acceptable in a younger patient)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Do I need a facelift to correct my chin sagging after being burred? I had a procedure done three months ago where the surgeon burred under and shortened the chin. It was done intra orally and the lower chin and my face is slack and looks like there is a protrusion. In other words it still looks like I have a double chin despite everything. I am not sure which procedure I need but I did include pictures. Also could a slight buccal fat removal be done in conjunction with this?
A: Intraoral chin reduction is almost always associated by loose chin skin afterwards and often fails to make a big improvement in the amount of chin projection. A submental approach to your chin reduction would be more effective. Whether this is addressed only by a submental tuck (submentoplasty) or would be rolled into a lower facelift would depend on where you see the area of improvements needed and whether you want the whole jawline tightened. It is not crystal clear in the pictures and the real test would be what happens when you bend your head down and where the skin rolls appear.
When referring to the buccal area, there is the area right below the cheekbone (the true buccal fad pad area) and the area that lies much lower near the mouth and jowl area known as the perioral mounds. (which is often confused with being the buccal area) I believe you may be referring to the perioral mound area by description and in the pictures. Perioral mound liposuction can be done in conjunction with any submental chin tuckup or facelift procedure
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a direct neck lift but have concerns about the length of the neck scar. I have had two facelifts but my neck wattle persists so I am tunring towards a more direct approch. Here are some pictures as I do not like my profile. Can I direct neck lift be done with a shorter scar?
A: There is no question that the final ‘piece’ to optimizing your facelift result is the central neck area. In a traditional direct neck lift, the bottom portion of the scar ends in an inverted T shape excision of skin along a horizontal skin crease which is usually over the thyroid cartilage. (most people perceive that it ends in a straight vertical line but that is a misconception) It ends like that to work out any excess skin. What really creates the sharp neck angle (besides the tissue excision) happens above that at the cervicomental angle) In a shortened or more limited version of a direct neck lift, the lower end of the scar can be completely vertical. (the upper end is now an upright T at the submental skin crease) This now becomes what is more classically perceived as a submentoplasty. This can certainly improve your neck wattle but not to the degree of the classic direct neck lift with the lower scar location. In conclusion, as long as the scar does not drop below the cervicomental angle area then that would be a good compromise between improvement and the creation of a scar.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had chin reduction done when I was 13 (intraoral approach), however, there are still problems with it and it never has looked exactly right. I think it may be soft tissue issues? It still has a bulbous shape, and ever since the surgery, has this odd-looking submental fullness. The underneath side of my chin sags and looks very unnatural and strange from the side; it has looked like this every since I had the surgery. I don’t understand why this is…. is this fat or muscle or why doesn’t it look exactly right?
Also, my bottom lip positioning is incorrect. My bottom lip needs to come down and out (more everted), because when i smile my bottom lip goes in over my bottom teeth. What I am wanting is a more normal-looking profile, less of a labiomental fold with a bottom lip that everts (instead of inverts) like normal, and a more sculpted chin (less fleshy and bulbous on the end and a more smooth profile without all the submental fullness.
I talked to you before about soft tissue reduction of the chin, but I now have x-rays which might be more helpful. I have attached my digital pics and the x-rays of my mandible (DICOM files). Would only a soft tissue reduction/augmentation be able to address my problems? Or do you think I need something done to the bone? Another ostectomy or bone burring? I want to get rid of this fullness underneath and get a more sculpted, normal-looking chin, instead of a bulbous one. What type of procedure or procedures do I need to fix these problems and improve my profile? Thank you 🙂
A: Good to hear from you and I remember your case quite well. Let me dissect all your issues one by one. First the submental fullness is a soft tissue isseu of too much fat and loose skin, which often happens from an intraoral approach to horizontal chin reduction particulalry if done by an osteotomy. Just that alone could be corrected by a submentoplasty procedure to flatten out the submental fullness and tuck the tissues under the chin. Secondly, the files of the x-rays you sent me were text and not the images and I have no way of opening them in an imaged format. You will have to send me the x-rays actual jpeg files. But even without the x-rays I believe you need further chin bone reduction/reshaping to have a more sculpted chin shape. The value of the x-rays for me is to know whether there is any hardware in there and what the bone shape looks like. Thirdly, no chin procedure is going to change the depth of the labiomental fold. That has to be addressed directly by either fat injections or a subcutaneous implant to soften its depth. Lastly, the lip position and how it moves is not something that can be reliably changed by surgery. The only option is to do a v-y internal mucosal advancement to create more eversion but this will not in the long-run move the lip position lower.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve had a consultation to receive chin liposuction as I rather dislike the definition of my jawline and chin angle. However, after studying myself more closely and researching the topic further online, I’m not sure liposuction will provide a significant result. From what I can perceive, my lack of jawline and chin angle definition is due more to the shape and size of my neck muscles (and perhaps my glands? and certainly my slightly recessed chin) then the little fat that is there. I’ve been reading about necklifts, in particular cervicoplasty, where an incision is made under the chin and excess fat is removed in conjunction with tightening of the platysma muscle. From my attached pictures, do you think this procedure might work for me best in an effort to define my jawline and improve my chin/neck angle? I realize you may suggest chin augmentation by implant to that effect, but I am not keen on that option (in my ideal examples, you will note that I have augmented the jawline only and not the chin). Could you please give me some information on the surgery and recovery time?
A: I would agree with your assessment that submental liposuction alone would be insufficient to achieve your ideal neck angle result. You will only end up about halfway there based on your imaging predictions. This is not just a fat issue as you have pointed out but a plastysmal issue as well..in conjunction with your shorter chin. A submentoplasty or isolated cervicoplasty would be a better approach. I don’t know if you can achieve your ideal goal as you have illustrated in the neck flexion image but it certainly would be better than liposuction alone. As you have mentioned, a submentoplasty or limited cervicoplasty is done by a small incision underneath the chin in which fat is suctioned and the platysmal muscles and overlapped and sewn together to tighten the neck angle. There is only moderate swelling and a very quick recovery. The biggest issue with cervicoplasties in young patients is to avoid any skin irregularities or ripples after it has healed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I just wanted to have a jawline. As you see from my pictures there really is no jawine. All I can see is that big neck and I always wanted too be able to wear a hat but when I do put a hat on all you see is my turkey neck. Man I want to someday to comfortably put a hat on. There is nothing worse than two chins but it could be worseso I just accepted it. I just finished working out after work, anything to try and prevent a third chin. I really am gratefulyou took the time to review my case.
A: Thank for sending the good profile pictures. I can clearly see your concerns and they are based on the issues of having some bony chin deficiency (with a ball of soft tissue on the end of it), a high hyoid bone and a relatively short neck. These three factors give you the jawline-neck appearance that you have and do make it a challenging problem. Necks like yours are not easy to improve in males. There is not just one procedure that will correct all three contributing anatomic issues so a dual approach has to be used. I would advance the chin with a sliding genioplasty to lengthen the jawline, pull some of the neck muscles forward with it and increase the chin prominence. That would also stretch out the redundant soft tissues of the chin over the advanced bone. At the same time, I would then perform a submentoplasty procedure designed to remove neck fat and tighten up the neck muscles from below to make a better neck angle. This combination (sliding genioplasty/submentoplasty) would make improvements as demonstrated in the attached computer imaging. This will not completely get rid of the neck skin roll that you are making when you tilt your head down but that would require a formal necklift which, may not only be further than you want to go at this point, but I would await to see your level of satisfaction with these other more ‘simpler’ procedures first.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, what is a mini facelift with a simple subtuck treatment? Is a subtuck treatment to the neck area, and how is it performed?
A: When you use the term ‘subtuck’, you are referring to the submental area of the upper central neck. That is an area that will not be affected by a mini-facelift unlike a full or regular facelift. In a mini-facelift (aka Lifestyle Lift amongst many names) the jowls and the face behind them is effectively lifted and tucked. But the submental area is not changed by a mini-facelift because it is a more limited type of facelift that does not reach this far forward. This is why some type of submental treatment, such as liposuction or a submental tuckup, often needs to be done at the same time as the mini-facelift to get a more complete result. These submental procedures are done through a small incision underneath the chin.
Not every mini-facelift needs to have submental manipulation, it just depends on how much loose skin or extra fat is in this area. I would estimate that two-thirds of mini-facelift patients do need submental attention as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a lower facelift/necklift that left me with a prominent (at least in profile) Adam’s Apple and showing some platysmal muscles under the chin probably because of lipo done in that area years ago. I’m wondering whether a tracheal shave would be helpful and possibly a resuturing of the platysmal muscles directly under the chin to smooth that area out? Thank you.
A: I suspect that the reason you have the submental hollowing is that either fat was liposuctioned from that area and the platysmal muscles not sewn together (unlikely) or the subplastysmal fat was directly excised and the platysmal muscles that were sewn together separated sometime after surgery. (very likely and most common reason) The thyroid cartilage has become unmasked due to the muscle tightening above it (it is carried down to it but never can be done over it or below it). This pulls the muscles and overlyng neck skin up and back, creating a much better cervicomental angle but not exposing the prominence if the thyroid cartilage. I have seen this complaint from necklift patients numerous times and it is usually thin women that are most predisposed to this potential aesthetic trade-off problem.
I would agree that the best approach is a direct tracheal shave and a limited submentoplasty using a z-plasty approach to overlapping the platysmal muscles. (to lessen the risk of a recurrent submental problem) This is a far easier procedure to go through than your original facelift with a very limited recovery.
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 am writing to request for your thoughts in chin ptosis correction, which I found out through Q&A’s on your website. I had a fairly large chin implant removed due to infection 2 years ago, which left me with my current chin ptosis condition. The implant was in my body for 10 months, so the capsule is still left in me for horizontal projection. I am happy with the projection it gives, except that the capsule sits high part of my chin (just below my lower lip), and there is a difference between where my lower part of my chin bone starts and where the capsule lies. Since the primary concern is loose skin, I would love to have some form of skin-tightening or skin-cutting without showing the gap between my capsule and my chin bone. (in picture I am grabbing the loose tissue) I consulted about this issue with a previous surgeon who placed an chin implantl and he just didn’t know what to do. He told me he has never seen this level of chin ptosis, and he just ended up recommending another sliding genioplasty and chin implant. I am personally satisfied with my current forward projection through capsule, and I am not sure if I will need more chin augmentation.
A: By definition what you demonstrating by grabbing is a procedure known as submentoplasty. To me your ptosis is really submental in location and not on the chin point at all. A submentoplasty procedure involves a curved submental incision under the chin to remove skin and fat and tighten the neck. I don’t think that will get rid of all your submental ptosis because to do so would involve a longer incision that I would not feel comfortable doing in a male with your skin pigment and ethnicity. The best result comes from a direct necklift but a vertical incision should never be done on your neck.
Dr. Barry Eppley
Indianapolis, Indiana
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
Indianapolis, Indiana
Q: Dr. Eppley, I had a chin implant, neck liposuction and a submentoplasty with fat removed under the platysma muscle one month ago. I am 32 years old and had a double chin that could not be improved by any other method. I wore a neck compression garment faithfully for three weeks after surgery. Despite this, I have very visible lumps and creases which did not exist prior to surgery. Will this resolve? What else can I do to help?
A: A submentoplasty combined with liposuction is a very good but aggressive procedure for neck recontouring. There is no question that it can do a good job of removing fat and tightening muscle, significant anatomic changes to improve a neck profile, but it does not remove skin. Thus it relies on the elasticity of skin to shrink down and produce the final shape. It is not uncommon for this procedure in some patients to end up with skin redraping issues. (irregularities, indentations, creases) That is the one knock on the procedure in my experience. It is still early so some of these skin issues will definitely get better with time. Whether they will completely go away remains to be seen and I doubt if there will be 100% resolution. But this is an issue of time and you will know more by six months after surgery. You would probably benefit by neck treatments such as massage or Exilis treatments which can help with skin smoothing and now is the time to do them before a lot of scar sets in.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I need your help as I have no jawline. My chin is very short, the neck seems to be missing and it appears as I almost have no lower jaw. This gives a profile that I am very self-conscious about. I make every effort so people don’t see me from the side. I know you are an expert in facial surgery based on your writings and patient photos so what do you recommend?
A: Lack of a well defined jawline and neck angle can be due to any one or combination of the following; chin/lower jaw bone prominence, fullness/fat in the neck and loose neck and jowl skin. Most commonly, the combination of a chin implant and neck liposuction can make a dramatic difference in the younger patient who often has a short chin and full neck. In older patients the sagging skin factors in significantly and some form of a jowl or necklift may be needed. There are exception to these two categories, such as the early aging facial patient with a good chin prominence who just needs some neck contouring through a procedure known as submentoplasty. But when someone describes themselves as having ‘no jaw’, this would indicate the problem is more than just one of the three anatomic components that make up the neck angle and jawline.
Dr. Barry Eppley
Indianapolis, Indiana
Q:Dr. Eppley, Can you tell me how to get rid of my pesky double chin? It bothers me tremendously. I am only 43 years old and my neck looks twenty years older! I am too young to look like this. I am at a good weight and haven’t been able to shake these two chins off no matter what I do. What do you recommend?
A: The ‘double chin’ appearance comes from two upside down hump areas. The first is the chin, which everyone has, but in the double chin patient it is often short or set back. This can make it appear that it is part of the neck when it should be a more distinct forward prominence of the jaw. The second hump or sag is the soft tissue of the neck. This may be just a lot of fat but is usually mixed in with some loose skin as well. This is particularly so in older patients who may have overall neck skin laxity. Given your relatively young age, I would envision that the anatomic composition of your double chin is a bony chin shortness and a collection of fat with some mild amount of loose skin in the neck.
Therefore, correction of your jaw and neck contour could be done by a combined chin augmentation and neck liposuction. It may also be beneficial to do a little neck muscle (platysma) tightening at the same time to get the best neck angle. I doubt if you need any removal of skin at your age and we would rely on the natural skin tightening that occurs after liposuction in good quality skin.
Dr. Barry Eppley
Indianapolis, Indiana
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