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Archive for the ‘necklift’ Category

Technical Strategies – Webbed Neck Correction with Trapezius Myotomies

Sunday, October 15th, 2017


The webbed neck occurs is a wide variety of medical conditions and has variable presentations. While most commonly associated with Turner’s, Noonan and Klippel-Feil syndromes where the webbed necks are severe, they also occur in lesser presentations that may have no specific syndrome associated with them. While non-syndromic neck webbing is less severe, it may be more aesthetically disturbing given that it is a solitary physical deformity.

The traditional methods of webbed neck correction use incisions and tissue rearrangements directly along the neck webs which are aesthetically unacceptable. While effective the visible scarring is not a worthy tradeoff in many cases particularly in the less severe neck webs. For this reason I use a posterior approach that employs a diamond-shaped skin excision. The upper half is in the hairline and the lower half is in the non-hair bearing neck skin. The middle angles of the equilateral parallelogram are placed along the horizontal axis of the maximum amount of inward skin pull needed.

The posterior neck skin is fully excised down to the fascia. It can be surprising how thick the skin and fat is on the back of the neck even in a thin person. Skin flaps are raised out to the lateral neck web lines on each side along the trapezius fascia. The fascia is opened along a linear line that goes out to the neck webs. With the trapezius muscle exposed its fibers are partially released from its lateral border for several centimeters inward. Midline fascial plication is then done on each side pulling in the sides of the muscle.

To complete the webbed neck correction, the skin is closed by changing the diamond-shaped excision into a vertical midline closure. The muscle and fascia work brings in the deeper structures while the skin closure provides the more superficial neck narrowing effect. Skin excision and closure alone will not create a sustained webbed neck corection.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Large Buffalo Hump Reduction

Thursday, August 3rd, 2017


Background: The buffalo hump is a descriptive term that universally applies to a discrete collection of fat on the back of the neck. Looking at the American bison it is easy to see why it has its name with the massive shoulders of the animal being amongst its most distinct features. But unlike the bison, the human buffalo hump is not muscle but fat.

The dorsocervical collection of fat in humans both unusual and distinct for two reasons. First, it is not a typical location for fat to deposit as it is not known for being a metabolic depot site. It may reflect the congenital location of brown fat which is known to be present in newborns but diminishes with age. Secondly what activates the enlargement of the dorsocervical fat pad is not precisely known. Certain medications and illnesses are associated with its development but it can also occur in people who do have these drug or disease associations.

Case Study: This 22 year-old male presented for treatment for his large buffalo hump deformity. He was a large adult man (almost 300lbs) but he did not have any of the associated triggers for its development. It caused him neck pain and restricted his neck extension. He was also socially embarrassed by it.

Under general anesthesia and in the prone position,  a three-hole liposuction approach was used. Using power-assisted liposuction with baskets as well as smooth round-tipped cannulas the very dense fibrofatty tissue was aggressively treated with an aspirate volume of just under one liter. (900ccs)

His immediate result during surgery showed the degree of improvement which largely made the back of his neck flat again. Unfortunately there are no good methods of after surgery compression for the back of his neck so he will have considerable swelling which will take more than a month to return to this intreoperative result.

The traditional method of buffalo hump reduction was open excision. Due to its very dense fibrofatty tissue it was felt that liposuction could not get an adequate reduction. And if one was using traditional ‘elbow-driven’ liposuction this would still hold true. But today’s many power-driven liposuction technologies make it possible to reduce denser and more fibrous fatty areas like the buffalo hump. While not every case has such dense fibrous fat many buffalo humps do.


  1. The buffalo hump deformity is an abnormal development of fat in the dorsocervical fad pad.
  2. It is a often a dense fibrofatty tissue that requires a mechanized or energy-driven liposuction method for removal.
  3. An open excision of the buffalo hump can usually be avoided.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Posterior Approach to Webbed Neck Correction

Sunday, March 26th, 2017


Background: A webbed neck, also known as a ptergyium colli, presents as wing-like skin extensions around the sides of the neck that extend down to the shoulders. One of its classic signs is that the occipital hairline follows down along the webs creating an m- or inverted v-shape to the hairline from the back. Significant neck webs are always syndromic and have well known associations with Turner’s, Noonan’s or Klippel-Feil syndromes.

But neck webbing is not always associated with a specific syndrome and I have seen numerous webbed neck patients that do not have any syndromic association or any other bodily symptoms. Their neck webbing appears to be an isolated finding or possibly they have mosaic Turner syndrome (absence of X chromosome in some cells) which results in milder symptoms than other types of the disorder.

In the treatment of neck webbing, the classic teaching is that the only effective treatment method is the use of Z-plasties along the line of the neck webs. While this is effective the Z-plasty scars would not be viewed as good tradeoff for the neck webs. I have never performed Z-plasties for neck webbing and never would. The scars are simply not acceptable particularly in milder forms of neck webbing.

Case Study: This middle-aged female presented with mild but visible neck webbing that she had her entire life. She did not have Turner’s or any other known syndrome and she was otherwise normal in every aspect of her physical and sexual development.

Webbed Neck Correction intraopWebbed Neck Correction intraop 2 Dr Barry Eppley IndianapolisUnder general anesthesia and in the prone position, a diamond-shaped ellipse of skin was removed with its two horizontal points oriented along a line drawn between the twos sides of the neck webs that would produce the greatest inward movement. The skin flaps were then undermined out to the webs bilaterally and the skin released from the fascia. Midline fascial plication was then done withu strong permanent sutures. The skin was was then closed in multiple layers, closing the diamond-shaped excision into a vertical linear closure.

JV Webbed Neck Correction result front view Dr Barry Eppley IndianapolisJV Webbed Neck Correction result back view Dr Barry Eppley IndianapolisHer one week after surgery results showed good improvement with the side profile of the neck being more vertical and not oriented obliquely outward. The early healing of the posterior neck scar line at suture removal showed a likely favorable outcome.

The old concept of treating neck webbing by Z-plasties should be abandoned for a posterior midline approach using skin excision and fascial release and plication. While this approach also creates a scar , it is placed in a location that has no aesthetic liabilities even if the scar widens.


  1. Webbed neck deformities are most commonly associated with Turner’s syndrome but smaller webbed necks can occur in isolation.
  2. Webbed neck correction depends on both skin excision and fascial plication on the back of the neck.
  3. Correction of the webbed neck results in a vertical scar at the bottom of the occipital hairline.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Liposuction Necklift

Monday, February 27th, 2017


Background: Aging of the neck is associated with numerous well known changes. The neck droops down as excess skin and fat develop in the center and sides of the neck. The underlying platysma muscle separates and allow the deeper neck tissues to come spilling out. All together a neck wattle or turkey neck is the result.

One of the major components of most neck wattles is fat. While removal of fat can be done by liposuction will that create an adequate ‘necklift’ or neck contouring effort. This is highly age-dependent. At younger ages the lack of  skin redundancy and its good elasticity allows for the neck skin to tighten and lift up. But at older ages neck skin excess and diminished skin elasticity make it more uncertain as to what the neck skin will do.

Case Study: This 57 year-old female was bothered by the shape of her neck. She had a reasonably thick fat layer but her skin was thin with numerous wrinkles in it. If possible she wanted to avoid any major surgery and was willing to see how much improvement liposuction alone could achieve.

Under general anesthesia (she was having other procedures as well) her entire neek was treated with small cannula power-assisted liposuction removing 26cc of fat.

Older Neck Liposuction results side view Dr Barry Eppley IndianapolisCA Neck Liposuction result front viewLiposuction can be a very effective for neck contouring method in the properly selected patient. Usually older patients are less than ideal for just liposuction because of their skin excess and diminished skin quality. But for the patient who wants to limit the extent of the surgery and are willing to accept that the outcome may be suboptimal, neck liposuction can serve as a test to determine if a lower facelift is really needed.


1) A sagging and full neck is a common development as one ages.

2) In the older neck liposuction alone will provide improvement but depends on what the overlying skin will do.

3) Neck liposuction is not a substitute for a lower facelift (necklift) but can be used as a ‘test’ to ultimately determine if one is needed.

Dr. Barry Eppley

Indianapolis, Indiana

The Subplatysmal Necklift

Monday, January 2nd, 2017


Reshaping the congenitally full neck or one that is drooping due to age is a common facial reshaping/rejuvenation procedure.While the aging neck is frequently thought of as due to loose skin, the naturally full neck is recognized as having deeper tissue problems than just skin. Both the origins of a low hanging neck and the neck lift technique used to treat it, however, must take into consideration all tissue layers from the skin down to the hyoid bone.

submental-incisionsubmandibular-gland-spaceIn the January 2017 issue of the Aesthetic Surgery Journal, a paper was published entitled ‘Subplatysmal Necklift: A Retrospective Analysis of 504 Patients’. In this well illustrated paper the authors go through a step by step surgical approach to all of the reachable subplatysmal structure and report their results on a very large patient series. Through a low submental incision (3 cms from the natural submental skin crease), all subplatysmal neck structures could be well visualized particularly the submandibular glands. The sequence included the initial removal of interplatysmal fat and elevation of the medial borders of the platysma muscle. The submandibular glands were located by following the anterior border of the digastric muscle to the hyoid bone. The gland capsule was opened and the medial half of the gland removed. Botox injections (10 units) were placed into the remaining gland and the gland capsule closed with continuous sutures. If indicated a subtotal resection of the anterior belly of the digastric muscle is also done. Hyoid repositioning can be performed by suture plication of the peri-hyoid fascia at the level of the pulleys of the digastric muscles. Lastly, a corset platysmaplasty is done.

A total of over 400 430 patients underwent this type of subplatysmal necklift. Not all patients had every subplastysmal structure treated with the most common being fat (84%), the submandibular glands (61%) and the digastric muscle. (18%) Complications included temporary weakness of the marginal mandibular nerve (6%) and salivary leak from the gland (2%) No hematomas or infection occurred.

Modification of the subplatysmal structures in neck contouring can include fat, the anterior bellies of the digastric muscles, the submandibular glands and the hyoid bone. Historically subplatysmal neck contouring has been avoided due to concerns of facial nerve injury and creating a salivary gland leak. This paper demonstrates that, while these complications do occur, they do not so at a high rate. Furthermore they are self-resolving issues without permanent sequelae.

This paper demonstrates that the subplatysmal necklift is a safe and effective neck contouring approach. It goes beyond the traditional neck contouring methods of subcutaneous neck liposuction and plastyma muscle plication. For those indicated patients it does volume reduction and creates subplatysmal support that the platysmal muscle alone can not do.

Dr. Barry Eppley

Indianapolis, Indiana

Necklift with Complete Platysmal Transection

Monday, October 24th, 2016


One of the most common features of the aging process is sagging of the neck. When more advanced the central neck become a repository for loose skin, fat and and the appearance of platysmal banding. While platysmal banding is part of every aging neck, it is usually only seen well in thinner necks with less subcutaneous fat.

platysmal-neck-bands-dr-barry-eppley-indianapolisMost necklift techniques involve some form of platysmal plication. This is where the split medial edges of the platysmal muscle are sewn together usually after some defatting as well. There have been numerous platysmal suture techniques described but at the core of them all is that is a platysmal tightening method.

In the October 2016 issue of the journal Plastic and Recostructive Surgery an article was published entitled ‘Complete Platysmal Transection in Neck Rejuvenation : A Critical Appraisal’. The authors used a necklift technique of full skin undermining complete platysmal transection and midline platysmal approximation. In 150 consecutive necklift patients operated on over a four year period, results were compared at 3 and 12 months to determine persistence of anterior neck tightness. Patient satisfaction was 100% at three moths which fell to 76% at one year after surgery. Physician assessment, however, showed that only 50% had no anterior neck skin excess and 55% had no recurrence of platysmal bands at the one year assessment period.

There were no major complications with this necklift technique such as nerve damage, large hematomas or skin necrosis. The biggest drawback was the prolonged edema (swelling) that persisted in the neck often out to two months after surgery. Two-thirds (67%) of the patients reported having a ‘hard neck’ for a long time.

Overall this necklift technique has a high patient satisfaction rate even out at one year after surgery. An interesting question about platysmal bands is why they recur after being cut. The authors propose that it could be de to either inadequate muscle resection, muscle regeneration or restoration of motor nerve function. Regardless of the mechanism complete transection of the muscle does not permanently eliminate the development of platysmal bands. This study provides clinical evidence that it does not.

necklift-dr-barry-eppley-indianapolisWhat this study shows is, to some degree what all plastic surgeons know, a necklift procedure is not permanent and begins ‘going downhill’ as early as 3 to 6 months after surgery. There is an expected amount of recurrent anterior skin laxity and platysmal bands by one year after surgery despite an aggressive neck contouring technique. Such information is valuable preoperative education information.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Direct Necklift

Saturday, October 22nd, 2016

Significant aging of the neck is most commonly treated by a neck lift, also known as a lower facelift. While earlier signs of neck sagging/fullness may be treated by liposuction and other more limited procedures, true neck wattles can only be treated by more traditional and aggressive approaches.

A lower facelift/necklift repositions the hanging neck skin back towards the ear and removes the excess tissue there. This requires incisions to be placed around the ears. Thus the tissue removed results in scars that are placed in relatively inconspicuous locations. This is a fundamental principle of facelift surgery. But men pose unique challenges in facelift surgery because of their often limited hair or short hairstyles around the ears. This makes it hard to hide the facelift scars and, as a result, may also make it difficult to get a good neck lift result.

direct-necklift-wattle-excision-dr-barry-eppley-indianapolisAn alternative technique in older men that have significant neck wattles is the direct neck lift. As the name implies the neck wattle is cut out directly down the center of the neck. The key to doing this surgery with the best scar result is how the pattern of skin and fat is removed. It is not just an elliptical excision of tissue down the center of the neck. If it were there would be dogears (redundant skin) at the top and bottom of the need of the elliptical excision. Rather the skin cutout pattern resembles the shape of a candelabra or urn. This places a smaller horizontal skin excision in the submental area and a larger horizontal skin excision at a lower neck level. This creates an I-shaped closure line in the neck.

The direct necklift is a tremendously powerful procedure for removing neck wattles. It is actually more effective than a traditional fuller neck lift/lower facelift because it removes the neck wattle directly. But it does so at the expense of neck scars and that is its major consideration. Fortunately the beard skin in older men (greater than age 65) heals very well. At this age the direct necklift offers a less invasive procedure with minimal recovery and avoids scars and potential hairline disruption around the ears.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Webbed Neck Surgery

Saturday, April 16th, 2016


Background: A webbed neck, medically known as pterygium colli deformity, is a well known but rare congenital neck condition. Skin folds are present along the sides of the neck from the back of the head behind the ears down to the shoulders. The hairline often follows the skin folds in their upper part. It is most commonly seen in Turner’s syndrome but occurs on congenital syndromes as well. The skin folds occur in varying presentations but can be quite pronounced in many cases.

The surgical correction of the webbed neck has evolved from original descriptions of z-plasties done directly along the skin folds. While successfully breaking up the skin folds, such a direct approach leaves unsightly scars that are rarely worth the trade-off.

The posterior approach to the webbed neck is the preferred technique today. This involves removing tissue from the midline of the posterior neck and wide skin undemining out to the skin folds. Closing the posterior neck defect then pulls the skin folds inward. (more posteriorly) A variety of posterior neck excisional patterns have been described from butterfly, M and Z-plasty patterns. While providing definite improvement in the appearance of the skin folds and keeping the scar fairly hidden (with long hair), partial relapse is common with the secondary skin relaxation.

Case Study: This 35 year-old Asian female had a congenital webbed neck from birth. She did not have Turner’s or any other known congenital condition. Her necks webs would be described as mild to moderate. She was teased a lot for her neck webs when she was growing up. Prior to surgery, she shaved the lower portion of her occipital hairline to aid the subsequent surgery.

Webbed Neck Surgery Markings Dr Barry Eppley IndianapolisUnder general anesthesia, the posterior neck was marked with red dots to mark the most tolerated lower extent of the tissue excision and midline closure and a modified T-shaped excisional pattern. The neck webs were vertically marked.

Webbed Neck Surgery tissue excision Dr Barry Eppley IndianapolisWebbed Neck Surgery fascial plication Dr Barry Eppley IndianapolisThe posterior neck skin and fat was excised down to fascia. The skin edges were widely undermined out to the skin folds. The fascia edges could be grasped and mobilized considerably to the midline.

Webbed Neck Surgery fascial plication completed Dr Barry Eppley IndianapolisThe posterior neck fascia was plicated in the midline with large resorbable sutures. This could be seen to bring in the skin folds at the side of the neck significantly.

Webbed Neck Surgery skin closure Dr Barry Eppley IndianapolisThe skin edges were then brought in to the midline and closed in a T-shaped pattern. Prior to the skin closure, multiple quilting sutures were placed from the skin down to the fascia to both eliminate deep space as well as take tension off the skin closure suture line.  Marcaine injections were done along the fascia as well as the greater and lesser occipital nerves to manage immediate postoperative discomfort. The posterior neck incisions were covered only with with tapes.

Webbed Neck Surgery before and after during surgery Dr Barry Eppley IndianapolisThe skin folds were completely eliminated with this webbed neck surgery technique. The neck was changed from wide neck ‘wings’ to an hourglass neck appearance.

Webbed Neck Surgery results Dr Barry Eppley IndianapolisWebbed Neck Surgery left side result Dr Barry Eppley IndianapolisWhen seen the next day after surgery before returning home, her webbed neck condition was completely eliminated. The combination of posterior neck tissue excision and midline fascial plication creates an improved and sustained result in webbed neck surgery.


1) Webbed neck correction requires a posterior neck approach with tissue excision and midline closure to prevent visible scars on the sides of the neck.

2) Midline fascial plication is critical to bring in the sides of the neck (webs) and relieve tension on the posterior midline neck closure.

3) This form of webbed neck surgery uses the same principles as midline platysmal plication in facelift or direct anterior necklift surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Direct Necklift for Large Neck Wattles in Men

Monday, September 28th, 2015


Background: Large amounts of weight loss from bariatric surgery or rigid adherence to a diet and exercise program cause the creation of substantial loose skin throughout the body. While much of this loose skin does occur around the abdominal and waistline areas, it does affect other body areas as well. The face and neck is one such area and it appears as a large neck wattle and extreme jowling. The greater the weight loss the more severe the loose skin that appears hanging off of the neck.

The standard treatment for a neck wattle, regardless of its cause is a lower facelift. (necklift) The fundamental principle of a lower facelift (I will call it an indirect necklift for the sake of this article) is that the loose skin in the neck is ‘chased’ back to the ears where it can be removed in a location where the incisions can be fairly well hidden in and around the ears.

The concern in many men about a lower facelift is how well the scars can be hidden based on their beard skin and hair pattern. The bigger the lower facelift that is needed the higher the risk that the incisions will need to be extended beyond the shadowing of the ears where they will be more visible. There is also the issue for some men, particularly older ones, of how extensive the surgery will be and how much recovery will be involved.

Case Study: This 65 year old male had gastric bypass surgery eight years previously with a stable weight loss of 120lbs. As a result of his massive weight loss he developed a lot of loose skin. One of the areas that bothered him considerably was his very large neck wattle. He wanted it gone but was not prepared to go through an extensive lower facelift to do it.

Direct Necklift Excision and Closure intraop Dr Barry Eppley IndianapolisUnder general anesthesia he had a direct necklift performed. A large candelabra pattern of skin and fat was excised down the central axis of the neck. Subplatysmal fat was removed and the split platysma muscle was sewn together from the chin down to the thyroid cartilage. The lateral neck skin flaps were then brought together in a modified H-pattern skin closure.

Direct Necklift after Massive Weight Loss result side view Dr Barry Eppley IndianapolisDirect Necklift result obloque view Dr Barry Eppley IndianapolisHe had his sutures removed in one week and by three weeks after surgery had largely recovered. His large neck wattle had been removed. He did not get a completely sharp cervicomental angle but that may have never been possible with his neck anatomy.

Direct Necklift after Massive Weight Loss result front view Dr Barry Eppley IndianapolisA direct necklift is an alternative to a full lower facelift in men with large neck wattles. It offers a far simpler recovery with fewer risks of complications and at a lower cost. For the older man who can accept midline neck scars, the direct necklift may be acceptable. The neck scars in older men and their beard skin can heal remarkably well in many cases.


1) Large amounts of weight loss often results in excessively sagging neck and facial skin, particularly in older men.

2) The standard treatment of a large neck wattle is a lower facelift with incisional patterns around the ears.

3) A direct necklift offers a ‘simpler’ approach to large neck wattles in older men than a standard lower facelift.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Case Study – Webbed Neck Correction with Otoplasties

Sunday, March 8th, 2015


Webbed Neck in Turner's SyndromeBackground: The webbed neck deformity is a congenital skin fold disorder that runs along the sides of the neck to the shoulders. Known technically as the pterygium colli deformity, it is known to occur in a large number of medical conditions but the most common are the genetic conditions of Turner’s and Noonan syndrome as well as Klippel-Feil syndrome. At birth there are smaller loose folds of skin on the sides of the neck but with growth the webs expand outward ultimately making it look like there is little to no neck.

Surgical correction of the webbed neck deformity is a very different form of a neck lift. It is challenging because of the thickened fascia that comprises the band and a low hairline that extends down along the webs. The most common surgical techniques are the use of modified Z-plasties. A Z-plasty is placed with the midline arm down the length of the web. The subcutaneous fibrous band is excised, the shortened trapezius muscle is released, and the hair-bearingskin flap is cut out. The anterior skin flap is rotated and advanced to join its mirror image flap from the opposite side of the neck at the posterior midline. Any remaining skin dog-ears near the shoulder are corrected with additional small Z-plasties.

An alternative technique is a purely posterior neck approach using a Butterfly correction technique. In this method, a butterfly-shaped portion of redundant skin is excised posteriorly and the lateral, superior and inferior flaps joined in a double Y midline suture line or even that of an X pattern closure. The Butterfly technique avoids the unnatural hairline and noticeable scars characteristic of a lateral Z-plasty method but does so with often a less than complete correction of the webs.

Case Study: This 9 year-old female who had Turner’s syndrome had large neck webs that completely obscured any visible neck. They extended from behind her ears out to her shoulders She also had protruding ears due to a lack of antihelical folds.

Webbed Neck and Otoplasty Correction resultUnder general anesthesia she underwent an initial Butterfly correction technique for her webbed neck in the prone position. At the same time, otoplasties were performed through postauricular incisions using permanent horizontal mattress sutures to create antihelical folds. Four months later she underwent a second stage webbed neck correction where a large posterior Z-plasty was performed using the previous scars from her first procedure to gain further reduction in the webs and to relocate the low hairline.

She had substantial improvement in her webbed neck and ear deformities. There remained some slight medial neck bands but there were no visible scars. All scars were in the occipital hairline and on the posterior neck.

Case Highlights:

1) Webbed neck deormities are most commonly seen in congenital conditions such as Turner’s syndrome.

2) Traditional webbed neck surgeries use z-plasties along the sides of the neck which can result in visible scarring.

3) A two-stage approach to correction of the webbed neck results in no visible scars along the sides of the neck or shoulders.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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