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Dr. Barry Eppley

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Posts Tagged ‘direct necklift’

Options in Contemporary Surgical Neck Rejuvenation

Sunday, December 8th, 2013


The neck, like the face, ages although it does so in a more simplistic fashion. With the neck it is only a matter of loss of the neck angle due to loose skin, fat accumulations and midline muscle separation. But with different degrees of neck aging at different times in life, the type of neck rejuvenation procedure that is needed changes. There are a variety of aesthetic neck procedures which include liposuction, submentoplasty, formal neck lifts (lower facelifts) and direct neck lifts.

Neck Liposuction Dr Barry Eppley IndianapolisThe reduction of neck fat by liposuction works best in younger people (under age 45 or so) who have good skin tone. One of the main principles of liposuction is that skin retraction is needed after fat removal to see its effects. However, in some older people with more loose neck skin that do not want a necklift, some good improvements can be seen with Smartlipo (laser liposuction) which does a good job with skin tightening. Liposuction in the neck must be aggressive (taking fat right off of the underside of the skin) to be most effective.

Submentoplasty Dr Barry Eppley IndianapolisSubmentoplasty is a less well known neck procedure for younger patients (under age 50 or so) that have both excessive neck fat and a loose or separated platysma muscle. Done through a submental incision under the chin, neck fat (above and below the platysma muscle) is done (by liposuction as well as direct fat excision) as well as muscle tightening/plication is done to create a more defined neck angle result. It can be a hard decision to determine who is best served by liposuction alone or whether the platysma muscle should be tightened after subplatysmal fat is removed by direct excision.

Facelift Dr Barry Eppley IndianapolisThe lower facelift or necklift, in the traditional sense, is for patients with more advanced loose neck skin/neck wattles/ turkeynecks (generally age 55 and older)  who need substantial neck skin tightening and resuspension. Most people aren’t that a ‘facelift’ is really a neck-jowl lift or a necklift. These are often interchangeable terms. But the concept of a facelift has changed…from the development and marketing of a limited jowl lift to a full blown extended facelift. Thus facelifts today can now be from as early as age 40 to any advanced age.

Male Direct Necklift Dr Barry Eppley IndianapolisThe most uncommonly performed neck rejuvenation procedure, a direct necklift, is done almost exclusively in older men . (65 years or older) Many older men do not want a formal facelift/necklift for either recovery or hairline concerns. It involves a direct excision of neck skin and fat as well as muscle tightening with the tradeoff of a midline scar. (which usually does quite well in the beard skin of men) Because of scar concerns, direct necklifts are not done in younger patients and rarely in even older women.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: The Direct Necklift for the Older Male Neck Wattle

Tuesday, December 3rd, 2013


Background: The neck sags with age due to the development of sagging skin and fat and the separation of the neck muscles which exposes the subplatysmal fat. These neck changes can become really pronounced as one reaches the sixth and seventh decades of life. This is the time that many men take notice of their growing neck wattles and may finally want to have it removed.

The standard method of neck rejuvenation in older patients, male or female, is the facelift. It is a procedure that is better described as a neck-jowl lift for it only affects the lower third of the face. It does so by using incisions around the ears and into the hairline for redistributing the loose neck skin up towards the ear where it could be removed. Good   scar placement around the ears depends on careful placement, adequate hair density and the willingness to accept a certain period of recovery due to the extent of the skin undermining.

Many older men, however, do not want an extensive procedure with a prolonged visible recovery. They may also not have the hairline to support the extent of incisions needed around the ears to get the neck adequately lifted and tightened. An alternative necklifting technique is the direct necklift. As the name implies, it is the direct excision of the neck wattle.

Case Study: This 76 year-old male wanted to get rid of his neck wattle but didn’t want to have an ‘extensive’ facelift to do it. His turkeyneck had been growing and he didn’t like the flap of skin that he was seeing when he tilted his chin down. Even with his goatee, the neck skin could not be hidden.

Direct Necklift Incision pattern Dr Barry Eppley IndianapolisDirect Neck Lift plastysmal muscle separationImmediately prior to surgery, a ‘cadelabra’ design was marked in the middle of the neck for the amount and pattern of skin and fat to be removed. Under general anesthesia the marked skin and fat was removed. This exposed the platysmal muscles which were widely split. (arrows in picture) The muscle edges were sewn together and the skin closed in an I-beam pattern with the horizontal portion in the submental crease superiorly and low horizontal skin crease inferiorly. The only dressing applied was antibiotic ointment.

Male Direct Necklift result Dr Barry Eppley IndianapolisThe sutures were removed one week later with minimal swelling and bruising. The neck wattle was completely removed and the neck angle was well defined. By six weeks later the redness of the scars had faded considerably and had blended in well with the surrounding skin. No scar hypertrophy of the vertical portion of the scar had yet developed. (although three to four months after surgery is a better time to judge whether this minor complication will occur)

The direct necklift is a very effective alternative to a facelift for the turkeyneck in older men. It is a short cut to a rejuvenated neck angle that does so at the price of neck scars. But these scars heal exceptionally well in the beard skin of the older male neck.

Case Highlights:

1) Neck sagging, often called a turkeyneck, is common in older men (> 65 years old) as they age.

2) Many older men want to have their neck wattle removed but don’t want to do a facelift to do it.

3) A direct necklift provides a fairly simple technique to remove the turkeyneck that has neck scars that are very acceptable in the beard skin of older men.

Dr. Barry Eppley

Indianapolis, Indiana

Options in Neck Recontouring – 1. Soft Tissue Procedures

Friday, August 24th, 2012


The shape of the neck has a major influence on one’s appearance, even though technically it is not part of the face. But because the neck serves as the transition point between the jawline and the shoulders, it is just as easily seen as the rest of the face. The neck shape, particularly its angularity, influences heavily the shape of the lower face particularly the jawline. A smooth-skinned neck with a well-defined angle is associated with a youthful appearance. Conversely a loose and saggy neck is synonymous with aging, the more sag the older one is perceived.

When looking at improving the neck, it is important to understand its anatomy for all of its constituent parts can be modified. The soft tissues of the neck include the skin, the fat layer both above and below the plastyma muscle and the platysmal muscle layer deep. The hard tissues of the neck are the superior jawline (composed of the chin back to the jaw angles) and the inferior thyroid cartilage in the midline and the horizontal clavicles bilaterally. The hard tissues of the neck create most of its prominent borders with the soft tissue draped between them. The neck can be thought of as three aesthetic triangles, a central inverted triangle straddled by an upright triangle on each side.

Most of neck recontouring efforts are geared towards creating a better  and more defined cervicomental angle. A smoother and more defined jawline above is another goal as well as any lower neck prominences reduced. Most of this is achieved by some form of fat removal and skin tightening/excision.

Liposuction Fuller necks in young patients can be treated by liposuction-assisted fat extraction. Liposuction relies on the principle of skin shrinking/tightening so younger patients with good skin elasticity are the best candidates. I prefer neck liposuction using a laser-assisted method, such as a Smartlipo probe. The generation of heat can only help the skin tightening process. While usually not an ideal procedure in older patients alone, I have been surprised in a few older patients (> 60 years old) who refused any additional procedures how much improvement they got. (although the result was not ideal)

Submentoplasty When the fat in the neck is not just above the plastysma and the neck angle is very obtuse, the next step up from neck liposuction is the submentoplasty procedure. This is a neck reshaping operation in which fat is liposuctioned through the neck but also removes fat under the muscle in the midline and tightens the muscle as well. This is done through a small incision under the chin and is also known as a submental tuckup. It is used for younger to middle-aged patients with a minimal amount of loose skin but too much fat. It is also used as a revisional procedure after a facelift when there has been some rebound relaxation of central neck tissues or residual skin remains right under the chin.

Facelift/Necklift Facelifts are easily misinterpreted as a procedure that affects more than the neck and jowls…but it does not. They are better described as necklifts or lower facelifts. While there are many different variations and techniques used for facelifts, and a lot of marketing that adds to the confusion, at its most simplistic level there are only two basic types… limited and full facelifts. Both approaches use incisions around the ear but the length and location of the incisions and how much change occurs in the neck or jowls. Limited facelifts with their shorter incisions around the ears mainly improves sagging jowls and has a bit of effect on the neck through a hammock effect. The neck can be more dramatically improved with this operation if it is combined with liposuction. 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 is the main problem, often even worse than the saggy jowls. With a longer incision that goes behind the ears, it has a powerful effect on changing the neck. It almost always incorporates liposuction of neck fat and tightening of the platysma neck muscles as well with the additional use of an incision under the chin. Most patients over the age of 55 years old need a full facelift.

Direct Necklift The most uncommon form of soft tissue neck reshaping is the direct necklift. While it is the most powerful and simplist method of a necklift, it is infrequently done because of the location of the scar. Rather than around the ears, the incision to do a direct necklift is right down the center of the neck. Loose neck skin and fat is directly cut out from the chin down to the thyroid cartilage. The platysma muscle is sewn tightly together as well. Closure of the neck cutout creates a vertical or zigzag incision. While this scar is objectionable to younger patients and most women, it can be the preferred approach for older men with large hanging neck wattles and who don’t want to undergo a ‘facelift’. Interestingly the beard skin of the neck heals remarkably well and has much less scarring than one would anticipate.

Dr. Barry Eppley

Indianapolis, Indiana

Non-Facelift Options In the Aging Neck

Friday, March 16th, 2012

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

Case Study: The Simplicity Of The Direct Necklift In Older Men

Monday, January 2nd, 2012

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 goateehelped 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

Indianapolis, Indiana

Turkeynecks, Older Men and the Direct Necklift

Monday, November 14th, 2011

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

Indianapolis, Indiana

Options in Neck Reshaping and Contouring

Friday, October 21st, 2011

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 withvarious 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

Indianapolis, Indiana

The Zipper Necklift For Neck Wattle Removal

Tuesday, December 28th, 2010

The neck wattle is one of the most bothersome of aging facial features, particularly for the older male. Men are often much more concerned about their turkeyneck than they are about the bags and hanging skin around their eyes. That neck wattle not only flops around but really stands out in a shirt and tie as it hangs down onto the collar. It is an unfortunate sign of a man’s age.

The traditional and most effective correction for the neck wattle, at any age, is a facelift. While highly successful, some men seek out a less invasive approach with a quicker recovery. The direct necklift may be an attractive alternative provided one is willing to accept a central neck scar. Such a necklift scar usually does better in a male than a female due the improved scar results that occur in bearded skin.

While the direct necklift involves the simplistic concept of a vertical cutout of central neck skin, the operation is actually more sophisticated and involves numerous nuances in technique. Not only is skin removed but the attached underlying fat down to the platysma muscle is removed as well. With a very wide diastasis of the platysma muscle, all subplatysmal fat down to the strap muscles can also be removed from under the chin down to the thyroid cartilage. The intramuscular platysmal gap is then closed by a vertical row of muscle plication sutures. These maneuvers help to compliment the skin closure in getting a much improved and often dramatic change in the neck angle that not even a full facelift can approximate.

Despite the striking improvement in the neck angle with these deeper tissue steps, the outward appearance of the neck scar is also critically important. While there may be some horizontal scars from the closure under the chin and in a lower horizontal skin crease above the sternal notch, the most important and visible scar is the vertical one. Historically, the vertical necklift scar is done as either a straight line or a straight line with a central z in the middle of it.

The problem with a vertical neck scar is that it runs perpendicular to the horizontal skin tension lines in the neck and is under tension. This poses the risk of hypertrophic scar formation. This is why in some cases a z-plasty is made in the central area of the scar. An alternative option that I have explored for vertical necklift closure management is a running broken line closure of a symmetrical fashion. Known as a running w-plasty, this is a common scar revision technique that can also be called a ‘zipper line’. This breaks up the tension along the scar line and reduces the risk of poor scar outcomes.

In the cutout design of a vertical necklift, the edges of the excision are marked and then a running w-plasty pattern drawn on the outside of it. The skin is then incised along the marks and the deeper portions of the necklift carried out in the usual fashion. This creates a saw tooth-edge appearance along the skin margins.

At closure, the limbs of the skin edges is interdigitated to create the zipper line closure. This requires a meticulous closure with fine sutures done under loupe magnification.

The zipper necklift is another option for direct neck wattle removals. It appears to be a good choice when the skin excess is not significant enough to require horizontal excision and closure extensions under the chin and in a low skin crease…if only a completely vertical excision is needed. It could also serve as an option for hypertrophic neck scar management should that be necessary from a previous direct necklift.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: The Direct Necklift for Female Turkeynecks and Neck Wattles

Sunday, November 21st, 2010

Background:Changes in the neck is one of the most bothersome facial changes that occurs as one ages. A sagging neck can ‘grow’ into a really significant neck wattle by the time one reaches their sixties and seventies. When the neck sags to this degree, it literally flops from side to side and hangs down from the chin all the way to below the thyroid cartilage. (adam’s apple) This neck wattle is often referred to as a ‘turkeyneck’.

The traditional treatment for any sagging neck problem is that of a facelift. The benefits to the neck in a facelift is that the hanging skin is freed and chased back to the ears where it can be removed and the resultant scars placed in the hidden crevices and skin folds of the ear. While this is a highly successful operation, certain patients may seek an alternative approach that is less extensive , more cost effective and has a quicker recovery.

This alternative approach is the direct necklift. While uncommonly done, it removes the neck wattle by directly cutting it out. The tradeoff for this more simpler neck solution is that of a scar running down the center of the neck. This scar in the older male usually does quite well because of its location in bearded skin. The hair follicles in the skin and the daily use of shaving (microdermabrasion) leads to good scar outcomes. Women, however, have a different quality of neck skin that is usually thinner and the creation of a neck scar is more of a potential concern.

Case: This 63 year-old female could no longer stand the hanging skin from her neck as it gradually became bigger. She was offered a traditional facelift but declined and wanted a direct necklift instead. She was also offered a chin augmentation to complement her necklift but she declined.

The markings for a direct neck lift is more than just a simple vertical elliptical excision pattern. This would create skin redundancies or dogears under the neck and below the adam’s apple. Smaller horizontal excisions are needed at both ends of the vertical wattle removal, creating more of a candelabra excision pattern.

The neck wattle is removed along the combined vertical and horizontal excision skin pattern, taking all of the underlying fat. This exposes the widely split platysmal muscle edges which are then tightened with individual sutures to create and support a sharper neck angle. This exposure provides a unique view of the deeper muscle anatomy of the aging neck.

The skin edges from the sides of the neck are then brought together in the midline after first bringing together the horizontal areas under the chin and low in the neck above the sternal notch. The deeper layers are closed with resorbable sutures while the skin is closed with sutures that will need to be removed a week later. The only dressing that is used are small tapes which are glued on over the stitches. There are no restrictions after surgery including showering the very next day.

She had a near painless recovery other than some tightness of the neck when trying to look up. She had her tapes and sutures removed a week later. This photo shows her appearance at the time of her suture removal ten days after surgery.

Case Highlights:

1) The direct necklift is a good option for the older woman with a significant neck wattle if one can accept the trade-off of amidline neck scar.

2) The direct necklift provides a dramatic tightening of the neck angle through platysmal muscle tightening and generous removal of the hanging neck wattle.

3) Widening and tightness of the central position of the midline neck scar may require revision through a simple z-plasty or steroid injections.

Dr. Barry Eppley

Indianapolis Indiana

The Scar from the Direct Necklift

Wednesday, September 1st, 2010

The aging neck is one of the most bothersome features of facial aging, whether it be a man or a woman. This is very evident as patients get older (greater than 55 or 60) and often is the sole focus regardless how the rest of the face is aging. For many men, the sagging neck is often their only facial aging concern.

Often a surprise to many patients is that the traditional facelift is the primary surgery to improve the sagging neck. While many perceive that a facelift is a total facial rejuvenation, they erroneously believe that the neck is treated differently with a ‘necklift’. Understanding that a facelift and a necklift is the same operation is a revelation for many.

For some older patients with severe neck sagging or a ‘turkey neck’, they simply do not want to go through a facelift. In most men in particular, the facelift concept and the lack of significant hair around their ears motivates them to pursue a different option. Rather than try and persuade patients to go through a procedure they don’t really want or can’t afford, I have used in my Indianapolis plastic surgery practice an uncommon option.

The direct neck lift is one limited form of facelift that just deals with the neck only. By cutting out the neck wattle directly, a dramatic change in one’s neck contour is achieved. It would be fair to say that the direct necklift produces a more dramatic neck profile change that is strongly resistant to future aging concerns caused by skin relaxation. Rather than shifting skin back in a traditional facelift, inches of skin and fat are permanently removed and platysmal muscles strongly tightened in the direct neck lift. It is simpler, faster, has next to no pain, and involves very little recovery of any significance.

But the beauty of the direct necklift is marred by one potential concern, which is why it is rarely done, that of neck scarring. That is the price that is to be paid for its simplicity and effectiveness. But how bad is this scarring? Is it slight or is it significant? Many who have never actually performed the procedure believe that the risk of poor scarring makes the direct necklift not a viable treatment option. That has not been my experience.

When speaking about necklift scarring, it is important to point out that the vast majority of patients I have treated are older men, age 65 or older. That is an important point for two reasons. The bearded skin of men allows for the most favorable s exposed scar location. Between the thickness of the skin, the healing potential of hair follicles and sweat and oil glands and the daily shaving (microdermabrasion scar treatment) that most men do, scars are set up to heal favorably. Secondly, this male population is very motivated as the other alternative (facelift) is even less appealing.

The scar pattern from a direct necklift is not a straight line. Vertical excision alone will leave redundant tissue under the chin above and along the thyroid cartilage below. Rather it is a vertical excision pattern that is combined with horizontal ellipses at either end, forming a ‘candlestick’ or ‘fishtail’ pattern. The very center of the closure in the middle of the neck will bear the zone of greatest tension. This is often relieved with a z-plasty to prevent central scar hypertrophy or widening. This is done in about half of the cases. Such an excision pattern has shown to produce remarkable neck changes in profile.

The scars from a direct necklift usually settle quite quickly and the typical early redness of scars fades by three months or so. While a very fine line vertical neck scar can be seen on very close inspection, it is largely inconspicuous in all men. The horizontal submental and low neck line scars become invisible. The redness of the scar persists longer in women and may be more visible which is why it is usually a gender-biased procedure.

While the potential scarring is an appropriate concern in the direct necklift, careful patient selection can make for a very satisfied patient. I have yet to formally revise any neck scars but have injected several raised scars of a cm or so in the tight central neck zone.

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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