An algorithm for neck rejuvenation
I want to look better, but I don’t want a full facelift.” A plastic surgeon hears this very frequently from a patient. What can a plastic surgeon offer a patient who wants to look younger with a nice facial rejuvenation but does not want a full facelift? It is essential to explain to the patient what a neck lift will and will not accomplish.
No one procedure is perfect for every patient. Prominent plastic surgeons have created simple and complex neck-management algorithms. For the sake of simplicity, I will divide my neck-management algorithm into three categories and address the ancillary procedures:
• liposuction only;
• liposuction and neck lift with suture suspension; and
• liposuction and extended neck lift with suture suspension.
Evaluating the Neck
The patient is initially evaluated in terms of his or her mental, psychological, and medical condition. An adequate history should be taken that includes medications the patient is taking that can increase risk of bleeding in the neck, allergies, and previous neck and facial surgeries. Patients should be asked to stop smoking for at least 2 weeks prior to surgery and 2 weeks afterward. Smokers have a higher incidence of wound dehiscence and should be cautioned repeatedly. A medical clearance from each patient prior to surgery is important.
Once a patient is deemed a good surgical candidate, his or her neck is examined to determine which procedure to recommend. The box on page 26 provides evaluation criteria.
An important question that a patient can ask during the consultation is, “If I do my neck now, can I do my upper face later?” The answer should be to give the patient the option to have the neck lift done first and the facelift done later, if the neck will not need to be redone, or to do the whole facelift in one operation. On the whole, aesthetic plastic surgery patients are intelligent, educated people, and they should have the appropriate information to choose the surgery that suits them, not the surgeon.
The recommendation for neck rejuvenation should follow a systematic approach. The initial decision point is whether to liposuction or not. If the neck needs to be suctioned, then the question becomes whether liposuction alone is sufficient. If there is skin laxity, liposuction is combined with a neck lift. The extent of the neck lift, and thus the length of the incision, is determined by the platysma and skin laxity.
Liposuction only is for the fairly straightforward neck. It is usually performed on people in their 20s or 30s who have excess fat in their necks but good skin elasticity. They should have no weight fluctuation or excess weight that renders the neck skin lax or the contour ill-defined. The platysma muscle should have good tone with little noticeable banding.
After the patient is anesthetized and intubated, the neck is infiltrated with tumescent solution. After the solution takes effect, liposuction of the neck is performed with two small incisions in the postauricular region. The postauricular incisions are completely hidden behind the ear, which patients appreciate (see Figure 1).
It is judicious to err on the side of conservative rather than aggressive liposuction, because a completely defatted neck can result in skin irregularity and an unattractive skeleton-like appearance. Care should also be exercised to avoid injuring the marginal mandibular nerve with aggressive liposuction.