The jawline is the defining feature of the lower face. It is quite simple from a structural standpoint being a u-shaped arc and serving as the transition between the face and the neck. But it can have lots of aesthetic problems that are extremely common complaints. A weak chin, a sagging neck, a double chin, jowls, and weak jaw angles are the main jawline issues that manu people have. Whether one is young or old, male or female, these jawline concerns can affect all due either to aging or a congenital structural defect.

The strong or well-defined jawline has become an important component of facial beauty and attractiveness today. With the advent of the internet and other electronic media, a new cultural standard for jawline aesthetics has emerged. Males contact me today and almost always point to the jawline of Brad Pitt and numerous less well known models as to their goal. Women similarly point to actresses like Angelina Jolie or Reese Witherspoon as their desired jawline look.

What makes up a pleasing jawline that conveys both attractiveness and a more youthful appearance? This always refers to a well-defined  and visible inferior border of the mandible that is straight from the jaw angle to the chin. The jaw angles are slightly higher than the horizontal position of the chin and there is a slight flare from front to back. The chin is more square in men than in a women whose chin is more narrow. Soft tissue that hugs the lower edge of the jaw makes for a well-defined neck angle and the absence of any jowls. It can be seen that the bone structure is the key to a good jawline which will also affect how the soft tissue may sag with age off of the bone.     

While I suspect a good jawline has always been a desired facial feature, many recent improvements and advancements in plastic surgery have made it more achievable. But there is not a single jawline technique that will work for everyone. A variety of bone and soft tissue surgical procedures exist and often more than one is needed to get the best result.

Chin and to a lesser degree jaw angle implants have been around for decades. But new improvements in implant shapes have made them more versatile and adaptable to a variety of jawline problems and are available off of-the-shelf. Chin implants that extend posteriorly to cover the prejowl area and those that have increased width to create a more square chin are but a few of the newer options. Better chin implant designs are still needed, particularly those that may allow for increased vertical as well as horizontal projection. Jaw angle implants have largely been in one style, that of adding more lateral fullness. But newer jaw angle designs allow for vertical height increase and stronger lateral flare as well.

But off-the-shelf chin and jaw angle implants can often not make for a completely straight jawline because they are not connected in the middle between the two over the central body of the mandible. Custom jawline implants can now be made that can create a central jawline augmentation that unites the chin and jaw angle areas. Custom designs may also be used when the size of the chin or jaw angles desired has greater dimensions that what off-the-shelf implants can achieve.

Soft tissue techniques for an enhanced jawline include a variety of well known procedures. Fat removal by liposuction, loose skin tightening and removal through differing facelift techniques, and neck muscle tightening can better redrape the soft tissues around the bony jawline. Two uncommon but useful soft tissue procedures are the submentoplasty and the direct necklift. A submentoplasty works best in the younger patient with a full neck where extensive fat removal and muscle tightening are done without skin removal. In contrast is the direct necklift which is for the much older patient who is willing to accept a neck scar for neck wattle removal and platysmal muscle tightening.

Contemporary jawline aesthetic surgery is more than just a chin implant or a facelift. It needs to consider all anatomical elements and combine a variety of bony and soft tissue manipulations to get the best lower facial improvement.  

Dr. Barry Eppley

Indianapolis, Indiana   

An improved neck shape is a desire for many aging men and women. With time, loose skin and sagging fat develop that create a full neck with a more obtuse angle. When seeing patients who seek a better neck and jawline, they are usually surprised when the concept of a facelift is presented. They may have come in for a ‘necklift’ or some other limited operation but they most certainly didn’t think they needed a facelift.

For some, the issue of a facelift vs a necklift is a matter of misunderstanding terminology. It is common that most people believe that a facelift alters everything from the forehead down to the neck, not just an isolated neck and jawline change. Once explained properly they are ready to proceed with what they called a necklift. But for others a facelift is simply more than they want to do even though it is the ideal procedure for their aging neck and jowls.

Besides a facelift, they are a variety of other smaller or less extensive procedures that can be used to reshape the neck. These include the options of liposuction, submentoplasty, chin implants and the direct necklift. Often putting together two of these procedures is done to optimize their effects. But none of these procedures should be confused with creating the same effect as a facelift in the aging neck and it is important to realize their limitations.

Liposuction of fat can be very effective in reducing neck fullness. But that is dependent on how much fat actually exists in the neck and, most importantly, the quantity of neck skin and its tone. Loose neck skin will not respond to liposuction the way many older patients would like. The neck may indeed get less full but the skin may retract poorly and leave more visible folds and irregularities. Even with liposuction technology such as Smartlipo, which aids the fat removal process by a heating effect, significant loose skin will not be dramatically tightened. While I have seen some surprisingly good results with its use in the older neck, it is not a replacement for an excisional or lifting procedure for loose skin. When using it patients have to be willing to accept these skin issues or be ready to have a facelift later if they want further improvement.

The submentoplasty procedure is another method of neck fat removal but does not rely on liposuction at all. It is the removal of fat from underneath the platysma muscle and is often done as part of a facelift. Through an incision under the chin, the fat is seen through the separated platysma muscles in the midline. When done in a facelift, I use a ‘kelly clamp’ technique to remove the upper portion of the fat pad and then close the muscles over it. For those fuller necks with a lot of subplatysmal fat, a submentoplasty can make a dramatic change in the neck angle in side view. But like liposuction, its success as an isolated procedure depends on how well the skin retracts, which is why it works best in younger patients. In older necks, such fat removal can create skin dimpling and a central neck indentation.

Skin removal in the neck can be done without a traditional facelift. It is not commonly done as one might expect due to the scars that are created. But for the right patient who is fully educated, the scar may be a worthwhile trade-off. The direct necklift uses a vertical removal of skin from the chin down to the lowest horizontal neck skin crease. But skin alone is not just removed. All of the fat underneath this skin and even subplatysmal fat can be removed. The platysma muscle is then sewn together in the most dramatic form of neck muscle tightening due to the visual exposure that the surgeon has. The direct necklift produces the most significant neck angle change, even compared to the traditional facelift. Other types of neck excision or lifts exist, such as a submental tuck or a necklift that uses incisions behind the ears only, but their effects are very limited.

A chin implant is often a surprising suggestion to many older patients when discussing their neck concerns. It is a complementary procedure that increases the prominence of the jaw and by so doing lengthens the upper neck. While not enough alone to change a neck as much as a patient would like, it is a common component of many facelift procedures. It can be used with any of the non-facelift neck procedures and is conveniently done through a submental incision.

While there are a variety of surgical options for neck rejuvenation in older patients, their effects are limited. What they can do should not be confused with that of a facelift (with the exception of a direct necklift) and should be chosen only because one is more interested in less cost and recovery. For the neck with a lot of sag and droop, none of these more limited procedures may be a good option.

Dr. Barry Eppley

Indianapolis, Indiana

Background: While the face in men ages just like in women, their primary concern is often largely that which occurs in the neck. As the male neck ages, it often hangs down like a wattle. While it does contain fat and the platysma muscle has separated in the midline, the loose skin makes up the biggest part of the sagging neck tissues. Often called a turkey neck or neck wattle, this neck appearance not only shows one’s age but gets in the way of any neck conforming clothing.

While there is little question that a traditional neck-jowl lift (aka facelift) is the aesthetically preferred approach for neck correction, many older men simply don’t want it. There are a lot of reasons why including extent of the surgery, amount of recovery, visible scars around the ears and cost. While some plastic surgeons may be uncompromising about a facelift only approach, there are older men who will rather live with their neck problem than undergo a facelift.

The direct neck lift has been around for a long time. I suspect that its history goes back to the infancy of facelift surgery where direct loose skin removal was the only surgical option. In an era of limited anesthesia and rudimentary surgical techniques and instruments, the easiest and fastest solution was used. In today’s world, the easiest approach is chosen when recovery and cost are the limiting factors.

Case Study: This 62 year-old male was bothered by his loose and floppy neck skin. He otherwise felt good about his age and appearance and was not concerned about any other aging facial areas. Besides its moving when he turned his head, he had trouble buttoning his shirts which accentuated the visible loose skin. He was on a limited budget and could take little time off work. Furthermore, he did not want anyone to know especially his coworkers.

Under general anesthesia, he underwent a direct necklift using a ‘candelabra’ skin excision design. While most think only of a vertical elliptical excision, this will leave a bunching of skin under the chin and particularly around the adam’s apple area. The extra skin at both ends of the vertical excision must be accounted for in the skin excision design. With the removal of the skin, all the fat underneath it is simultaneously removed. The platysma muscle is then always seen widely separated and it is sewn with interrupted sutures from under the skin down as far as it can be brought together. No drain is used. The skin is closed with dermal resorbable sutures and interrupted permanent skin sutures. Only tapes are applied over the incision lines and no other dressings are used.

His skin sutures were removed in 10 days. There was the typical neck mild bruising, very minimal swelling and a red suture line for weeks after suture removal. The result was immediate with a 90 degree angulation of the neck at the time of skin closure that did not change at any time after surgery. Within a few months, the neck scar faded and was only perceptible on the closest inspection.

Interestingly, he stated that no one ever noticed that he had undergone any surgery or asked about it. I suspect his goatee helped distract or hide anything that happened in the neck But everyone did say he looked refreshed and more youthful.

Case Highlights:

1) Older men with neck wattles or turkey necks desire a simple solution to their aging neck concerns. They do not want a traditional facelift.

2) The direct neck lift provides a simple and extremely effective neck contouring procedure with minimal recovery.

3) The aesthetic liability of the direct neck lift is a scar but this is minimized due to the hair-bearing skin of the male neck.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

Indianapolis, Indiana

Facial aging affects everyone but men almost always delay considering its treatment until the condition is more advanced. Many more women undergo some form of a facelift than men. No one knows the exact average of men vs. women who undergo a facelift, but it would be fair to say that the age difference is at least ten years if not more.

What really drives a man to consider a facelift is the aging changes in the neck. A sagging neck, often called a turkeyneck, is the most compelling reason for men to undergo some plastic surgery improvement. The droopy neck skin and tissue bands, besides making for an older appearance, also interfere with the comfort of wearing shirts. By the time a man has presence of a real turkey neck they are usually at least 65 years of age or older.

A facelift, with its incisions in and around the ears, is a very effective changer of the jowl and neck area. The greatest benefit achieved with a facelift is in the neck and this is why the terms facelift and necklift are often used interchangeably. But a facelift in men poses challenges when it comes to hiding scars around the ears and getting complete elimination of a significant neck wattle. In addition, many older men do not want to undergo the extent of the surgery and recovery of a traditional facelift procedure.

An alternative to a facelift in the older man is a direct neck lift. Rather than chasing the neck skin back to the ears for its removal in a standard facelift operation, the direct necklift removes the skin and fat of the turkeyneck by removing it where it hangs. This greatly simplifies the operation and makes for virtually no real recovery. And, interestingly, the change in the neck is nothing short of dramatic and will last longer than that of a traditional facelift. When done over age 65 it will largely last the rest of one’s lifetime with the reappearance of a central neck wattle as unlikely. This is also an operation which can be done fairly comfortably under local anesthesia with oral sedation. This means that men of any age, almost regardless of their medical condition, can be successfully treated.

The trade-off to all of these direct necklift benefits is that there will be a fineline scar down the center of the neck. While no such scar should be taken lightly, the beard skin of men is a particularly favorable area for such scars to heal inconspicuously. It also helps that most men perform daily microdermabrasion scar therapy, also known as shaving. And if one wears a beard then the scar is particularly irrelevant.

For an older male with a significant neck waddle, a direct neck lift can be a very simple and uncomplicated procedure that can quickly get the results many men desire. A direct neck lift produces an immediate tightening of the neck and makes it look like it did twenty years ago in many cases. Such an operation easily fits into the lifestyle of the older male who is looking for a neck change that is both quick and simple.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

The shape of the neck is an important aesthetic structure of the face. When it is well defined with a sharp angle definition (between 90 to 120 degrees in profile), it makes the chin and jawline more prominent and flattering. When the neck angle is obtuse or completely open (straight), the jawline becomes obscured and less aesthetically pleasing. The neck can be seen to have a major influence on how the entire lower third of the face looks. As one begins to age, the neck tissues become loose and begin to sag. For some, even at a young age, they have a naturally full with an obtuse angle due to a thicker fat layer and a lower positioned hyoid bone.

While genetics, gravity and time work against a shapely neck with a good angle, there are a number of plastic surgery procedures to improve the aesthetic appearance of the neck. First, however, a few comments on non-surgical reshaping methods. While creams and exercises are touted to improve the shape of the neck, none have been proven effective for making noticeable changes. Some modest changes can be made in the appearance of jowls and neck skin sagging in those who have good skin elasticity with various transcutaneous energy therapies. (e.g., BBL or Skin Tyte) These are not to be confused with surgical results but there can be visible improvement. Injectable Botox can also be used to treat prominent vertical platysmal neck bands. These are best viewed as treatments neck for those that don’t have enough of a problem to justify surgery or for those who do but prefer to try a non-surgical approach first.

Full thicker necks with good skin can be treated solely by liposuction. Removing fat allows the skin to shrink and tighten up to reveal the shape of the underlying platysma muscle. While traditional liposuction is effective, the additional use of a laser-assisted technique can help improve the results. Smartlipo, which uses a fiberoptic laser probe, creates heat which not only helps melt fat but can create a skin tightening effect as well. While neck Smartlipo is ideal for younger patients due to their better skin quality, I have seen a few older patients with impressive neck changes as well.

The next level beyond neck liposuction is a submentoplasty. This is a neck tightening operation that not only removes fat by liposuction but tightens the platysma muscle as well. It is performed through a submental incision in which some small amount of loose upper neck skin can also be removed. Also known as a submental tuckup, it can be effective for the very beginnings of neck sagging in younger patients with good skin. It is also historically used after a facelift when some submental skin sagging develops (rebound relaxation) in the first year after surgery.

Facelifts are the primary procedure that can create the most effective change for the aging neck. Facelifts, also called necklifts, can be thought of as being two fundamental types either a limited and full type. Both use incisions around the ear but the length of the incisions and what effects they create in the neck and jowls is different. A limited facelift, which goes by a lot of marketing names (Lifestyle Lift, Quicklift etc), has as its main effect the smoothing out of sagging jowls with a more limited effect in lifting neck skin. It is best used in patients whose primary complaints are about their droopy jowls and not their necks. Full facelifts are used when the neck problem is more significant and its improvement is the main objective of the surgery. It is the most powerful changer of both the neck and jowls and usually also incorporates liposuction of neck fat and tightening of the platysma neck muscles. Chin augmentation with a facelift can also be helpful in giving a more defined jawline.

One other approach to the sagging neck is that of the direct necklift. Unlike facelifts in which the incisions and the direction of skin lifting is based around the ears, the direct necklift removes loose neck skin by excising it down the center of the neck…directly if you will. This is a simpler approach to a necklift and is a very powerful reshaping method of the neck but it does so with the trade-off of a midline neck scar. This can be a preferred procedure for older men (greater than age 65) who prefer the least recovery and have large hanging neck wattles. Male beard skin heals remarkably well and I have not found the neck scar to be a visible concern after it heals.

The last area of neck reshaping, which has nothing to do with age, is the prominent Adam’s apple or thyroid cartilage. For those that have too strong of a neck bulge caused by the strength of the paired cartilages of the Adam’a apple, this can be reduced by shaving the prominence down. This is done through a small horizontal neck incision directly over the prominence. It is a virtually painless procedure with no recovery and a result that is immediate. Most patients obtain results where the size of the bulge is dramatically reduced and a few will end up with a completely smooth neckline.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana