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Posts Tagged ‘neck liposuction’

Case Study: Liposuction of the Large Male Neck

Thursday, July 24th, 2014

 

Background: The shape of the neck is one of the most important aesthetic facial areas. Having a shapely neck allows the chin and the jawline to be more clearly seen which not only creates improved facial definition but creates a more youthful look. This is evidenced in patients who undergo weight loss and those who have facelift/necklift surgery.

The anatomy of the neck is fairly simple and has three distinct structures that are interdependent. There is the overlying skin, the underlying platysma muscle and the intervening skin.There are also structures underneath the platysma muscle (fat, submandibuar glands) but there are not as easily accessed or changed. How much loose skin and fat one has plays a major role in the shape of one’s neck.

Male Bull Frog Neck Dr Barry Eppley Indiana IndianapolisIn a large or ‘bull neck’ the contribution of the fat can be considerable. This is most frequently seen in men and women who often carry excess weight. This is no surprise given what percent of fat makes up the neck. The heavier in weight one is, the bigger the neck usually is. Weight loss can help reduce the size of the neck but that alone often is not completely successful.

Case Study: This 45 year-old male wanted to improve his neck. He was a large man but carried his weight well due to his height. But his large neck was disproportionate to how the rest of his body appeared. In reviewing the options for neck contouring (liposuction, liposuction with submentoplasty and a necklift/lower facelift), he opted for liposuction alone without any tissue excision. He did so with the understanding that the neck contour change would be the most limited and would only be about a 1/3 of that of a necklift.

Large Neck Liposuction result side viewUnder general anesthesia, the neck was infiltrated with a lidocaine and epinephrine solution. With small cannulas from puncture skin entrance sites under the chin and behind the earlobes, the entire neck was aspirated of fat from the supraplastysmal/subcutaneous layer. A total of 38cc of fat aspirated was obtained. A compressive neck dressing was applied.

Large Neck Liposuction result oblique viewIt usually takes at least six weeks after neck liposuction until most of the swelling, hardness and lumpiness resolves. It is common and to be expected due to gravity that prolonged fullness and stiffness of the tissues will be persistent in the lower half of the neck for awhile. The final result of any neck liposuction procedure should not be judged until three months after the procedure. The assurance of a final result is when the neck feels soft, the numbness of the skin is gone and it longer longer feels sore or hurts when squeezed.

The success and limits of neck liposuction depends on what the skin will do. How much will it contract and shrink up? That will depend on how much extra skin exists and how much elasticity it has. Generally male neck skin has a better ability to contract than females due to thicker skin and more innate elastic fibers. But there is a limit to skin contraction and almost all full large neck liposuction results will not be a cut and sharp cervicomental neck angle. There will be improvement but more significant results require skin management as well.

Case Highlights:

1) Large full necks are an aesthetic challenge because of the amount of excess skin that exists.

2) In younger patients with thicker skin that may have some remaining elasticity, liposuction alone can have a positive effect without risk of loose residual skin.

3) The results of neck liposuction can always be followed by a secondary necklift for further improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Fat Compartments in the Neck – Implications for Neck Contouring Surgery

Monday, May 5th, 2014

 

Neck Fat Removal Dr Barry Eppley IndianapolisFat in the neck is one of the major contributors to its shape. Large amounts of fat create full and/or droopy necks and work against a pleasing neck angle and profile. As a result, the removal of fat is part of just about every neck contouring procedure from liposuction to necklifts. The neck is usually defatted by liposuction at the supraplatysmal level but may also undergo direct excision at the subplastymal level in other neck contouring operations. (e.g., submentoplasty)

In the quest for optimal neck contouring and maximal fat removal, it is helpful to know where the fat compartments are in the neck and their contributions to the overall fat volume. This would help to understand what type of neck changes can be done and what procedures may be needed to fo them.

Neck Fat Compartments Dr Barry Eppley IndianapolisIn the May 2014 issue of the Aesthetic Surgery Journal, a study was published entitled ‘ Defining the Fat Compartments in the Neck – A Cadaveric Study’. In this study the anatomic compartments of the neck and their quantity and relationships were evaluated in cadaver heads by dissection. Supraplatysmal fat was found between the skin and the platysma muscle, and it was divided into suprahyoid and infrahyoid fat. Subplatysmal fat was found deep to the platysma and between the inner edges of the anterior digastric in the midline ad was also divided into suprahyoid and infrahyoid compartments. Lastly, the very deep fat below the anterior digastric muscles was identified as its own compartment.

Their findings shows that roughly 50% of the fat in the neck was in the supraplastysmal space. The subplatysmal fat accounted for roughly 25% and the remaining 25% was around the submandibular gland. The very deep fat was minute, accounting for only 1% of all neck fat.

Submentoplasty Dr Barry Eppley IndianapolisWhat this study shows is that the most commonly treated area of the neck for fat removal done by liposuction is the supraplatysmal space…and this accounts for only half of all neck fat. This means that many patients may not be able to achieve optimal neck contours with liposuction alone. In some cases the subplatysmal neck fat needs to be removed for a more significant neck contour improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Liposuction for the Full and Aging Neck

Wednesday, April 30th, 2014

 

There are many signs of aging and most look to the face to see them. But the neck is one of the first areas above the shoulders to show it (second only to the eyes) but is often only recognized as aging much later. When it comes to neck aging, there are three issues that are bothersome, too much fat or fullness, loose skin and neck bands or cords. Aging causes the last two but a fuller neck can occur even in a younger patient who has otherwise not even started to age yet.

Neck Liposuction result front viewAs an isolated neck problem, one may have inherited a fuller neck or can develop one as an early sign of neck aging through fat accumulation. (technically fat cell enlargement) Liposuction can be en effective treatment strategy as a fat removal method. While numerous other non-surgical treatment options exist, from fat dissolving injections to external energy-based devices, none currently are as effective or as efficient at fat removal as liposuction.

As a stand alone procedure, liposuction of the neck is best done on younger patients (less than 50 years old) who still have reasonably good skin tone. It does not work well for those that have loose skin or any significant amount of neck (platysmal) banding. The fat that is removed will be permanent unless one undergoes significant weight gain, making it an effective procedure. But not all fat cells are removed, since this is an impossibility, so fat regrowth is possible but only under extreme circumstances.

Neck Liposuction result side viewThe more relevant issue in liposuction of the neck is how the overlying skin adapts to the fat that is removed to create the new neck contour. The excess fat causes what is perceived as an excess of skin that must be managed for a positive benefit to be seen. Neck liposuction uses the principle of skin retraction to ultimately show the results of the procedure. While many patients fear that the skin will fall down away from the neck, this never occurs in skin with good elasticity and the skin always ‘sticks back up’ for an improved contour. This effect can be significantly diminished in skin with poor elasticity and laxity.

The procedure can be done under local anesthesia as a stand alone operation although many patients opt for a little IV sedation for optimal comfort and amnesia of the actual experience. While immediate changes in the neck are seen by the surgeon at the procedure’s conclusion, it takes time for patients to ultimately see the same. The swelling and bruising that ensues obscures the results and requires complete resolution to see what the surgeon initially saw. Some refer to this aesthetic recovery as ongoing neck tightening but that is a rather glorious way to describe it. Rather it will be lumps, irregularities and firmness that is felt and these temporary problems can initially be disturbing. It takes a full four to six weeks to have a near full recovery from neck liposuction and to be in the benefits phase of the procedure.

Much is made of the different liposuction technologies, most of them claiming superiority of results and recovery. While every liposuction technology has their own unique merits, the small area of the neck obscures any real benefits that they may have to offer. Small cannula traditional liposuction, done through a small incision under the chin and possibly behind the earlobes, offers good and predictable results.

Neck Liposuction with Chin Implant Dr Barry Eppley IndianapolisThe effects of neck liposuction can be enhanced further when done with either chin or jawline augmentation. When the chin projection is underdeveloped and the jawline support weak, chin or jawline implants can improve the neck reshaping efforts. Unlike neck liposuction, jawline skeletal augmentation produces a permanent and lifelong change.

While liposuction is a good neck contouring procedure, it is not a permanent one. As time passes and one ages, the neck skin will eventually loosen and bands will eventually appear. These neck changes will require further corrective surgery. How long a neck liposuction will last depends at what age it was done.

Dr. Barry Eppley

Indianapolis, Indiana

Necklifts for the Younger Patient

Sunday, December 2nd, 2012

 

While the face in theory ages evenly, one’s concerns about different facial changes is not. Besides the eyes, the neck is a frequent target of aging dissatisfaction. While the neck is composed of various tissues, one wants see is loose and hanging skin. This makes one yearn for the days when the skin between the chin and neck was firm and taut and a more defined neck angle existed. While styles and fashion have changed over the years, a sharp and clean neckline has always been a youthful image.

While the neck has always been a physical disdain of aging, what has changed is the age at which these concerns arise. Turkey necks and wattles are understandable neck concerns, but they represent older patients often in the sixth, seventh and eighth decades of life.  Ever since Nora Ephron’s book ‘I Hate My Neck’ was published, it was like a light bulb when off for many younger people.  Younger people, women and men alike, now appear in the fourth and fifth decades, to do something about their loosening neck skin. The reality is that the publication of the book was merely coincidental to this interest. The wide spread use of Botox and fillers has filled many a plastic surgeon’s office with early aging patients where the opportunity to discuss these concerns can easily happen.

The interest in addressing the earlier changes in neck aging has led to a variety of surgical and non-surgical treatments. A host of energy-driven devices exist for neck tightening, like Exilis and Ultherapy, but these are really bridging therapies until the time comes when one is ready for a more definitive surgical approach. Some fat shrinkage and skin tightening may work well for more minor neck droops, but really significant and and longer-lasting results requires tightening the muscle and skin to resist the never-ending effects of gravity.

Necklifting options today range from under the chin approaches (submental incisions) that use skin tightening caused by fat removal and/or muscle tightening and more traditional approaches (facelift) that use skin shifting and excision by incisions around the ears. Most younger aging neck patients are going to usually benefit by submental approaches and these are of the greatest interest because they are ‘less’ surgery with a quicker recovery. By definition a submental approach involves a small and inconspicuous incision right under the chin. It can be just a few millimeters when only liposuction is used. The heat created by the use of Smartlipo is a reall complement to the any fat removal done. For someone with a full neck but good thick skin, this could be all that is needed to create a better neck contour.

The most unknown necklift is that of the submentoplasty or platysmaplasty. Through a slightly larger submental incision, fat is first removed from under the skin but the cornerstone of the procedure is the muscle tightening. The sagging platysma muscles are sewn either back together or folded onto themselves in an up and down fashion creating an effect like a corset on the waistline. (which is why this procedure is also known as a corset platymaplasty) This shortens the vertical length of the muscle, pulling the neck angle upward  and with that the overlying skin as well. Other muscle innovations create slings from one side of the neck to the other using permanent sutures to create a hammock-like effect with special instrumentation for passing these sutures into the correction position.

While not as common, a few will have a neck problem that is not primarily fat but just loose skin. Skin laxity is a less frequent cause of younger patients but definitely becomes more of an issue as one crosses the half century mark. Loose skin in the neck, if not too severe, is managed by a smaller neck-jowl tuck-up or one of the many variations of short scar or limited facelifts. While less skin is removed than in a traditional facelift, the tightened on both sides of the jawline creates a hammock-like effect across the midline of the neck pulling it tighter.

The revolution in sagging necks is that more and more younger patients are turning to necklifts as stand alone procedures…changing for some the title of their own book ‘I Love My Neck!’

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

Case Study: Smartlipo Neck Reduction and Contouring

Tuesday, May 1st, 2012

Background:  The heavy or fat neck is a common problem in younger patients who often have a concomitant body fat issue. The neck is often a symptom of the patient’s overall weight and its size may yo-yo very much like their body does with cyclical weight changes. But for many of these patients, weight loss is not the total solution for their heavy neck and rarely results in a conpletely satisfying neck change.

Unlike the older patient, patients under 45 or 50 years of age rarely have signficant skin excess with their full necks. While there is some skin excess to be sure, it is not a large amount and only appears that way with a sagging convex neck profile due to the amount of fat. Their skin is almost always thick with reaonable elasticity.

Liposuction of the neck is a very common procedure and is done in conjunction with other procedures (e.g., facelift) as much as it is done by itself. It is an above the platysma muscle cannula technique for subcutaneous fat removal. There are other fat compartments, which can be significant, that are below the platysma muscle and are not accessible by cannula extraction. If present, these need to be removed as part of a more advanced neck contouring procedure known as a submentoplasty.

Liposuction technology has advanced over the past fifteen years, primarily in how the fat is mobilized prior to suction evacuation. One of these technologic advancements has been the use of fiberoptic cables to deliver energy (heat) directly to the fat layer. This has become widely know as laser liposuction, with the brand name Smartlipo as the most recognizeable market name. While often percieved as ‘zapping’ fat, this is not how it really works. It is more about raising the internal temperature to a level that is considered damaging to fat cells. This is generally in the range up to 45 or 46 degrees C. At this temperature level, the collagen in the skin is also induced to shrink and contract, theoretically aiding the necessary skin contraction needed for a good contour result. 

Case Study: This 40 year-old female wanted to get rid of her fat neck. It had always been there as she struggled with her weight over the years. She had recently lost 30 lbs but her neck did not change significantly. It had gotten a little smaller but not nearly enough for her satisfaction. She stated people would look at her neck and tell her she needed to lose weight.

Under general anesthesia, she underwent other body contouring procedures but her neck was treated by Smartlipo liposuction. After tumescent neck infiltration, the submental and lateral neck areas were treated by initial fiberoptic probe tunneling raising the temperature to 47 degrees as determined by internal measurements. Cannula extraction was then done, removing 55cc of aspirate.

Her postoperative course was typical for any form of neck liposuction. While there were visible improvements in the size of her neck initially, considerable swelling and firmness existed for three weeks after surgery until it began to soften. By six weeks after surgery, the neck was much softer but with a few areas of firmness and was still tender to squeezing and massage. By three months after surgery, the neck was completely soft and the skin had resolved all of its numbness. The final shape of the neck could be appreciated.

Case Highlights:

         Liposuction of the full or fat neck can effectively reduce the fat content above the plastysma muscle but the quality of the result will ultimately be determined by the degree of skin contraction.

         The type of neck liposuction performed may offer improved results if it aids in helping the skin to contract. Smartlipo provides a dermal heating effect that adds a theoretical effect on skin shrinking.

         Recovery after neck liposuction is a process that, while some immediate effect is evident, takes several months to see the final result.

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

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

Neck Rejuvenation with Liposuction vs. Submentoplasty

Monday, July 4th, 2011

A lower facelift, technically a neck-jowl lift, is the standard approach for improving an aging neck or an obtuse cervicomental angle. This has been historically true but as the average age of people seeking neck and jawline improvement continues to lower, some altered approaches are needed. Younger people do not want a ‘facelift’or an extensive procedure but seek something less invasive with a quicker recovery. In the properly selected patient, liposuction of the neck or a submentoplasty may just be what they are looking for.

These minimally invasive neck procedures are usually best done for patients in their 30s and 40s, although I occasionally have treated older patients as well with them. The key is the quality and amount of neck skin and how much fat there is. This can be determined by feeling the neck, pinching the neck skin and having the patient swallow. Full necks or those with an obtuse cervicomental angle usually have fat both above and below the platysma muscle. Knowing whether the removal of fat is needed below the muscle is important in determining whether liposuction alone or a submentoplasty is needed.

What is the difference between liposuction and submentoplasty? Liposuction is well recognized and exclusively removes fat through a small skin nick under the chin. It can effectively remove supraplatysmal fat in the central neck, jowls and out close to the anterior border of the sternocleidomastoid muscle. A submentoplasty incorporates liposuction but goes further. Through a larger submental ckin crease incision, a skin flap is raised with facelift scissors after liposuction has been initially done. The platysma muscle is then opened down the middle with a ‘cautery clamp’ technique. Subplatysmal fat is then removed and the muscle edges put together with sutures. (others have described their method of submentoplasty, this one is the way I prefer to do it)

Like liposuction, a submentoplasty ultimately shows its degree of improvement by the contraction of the overlying skin. This is why the thickness and elasticity of the neck skin is so critical in determing how successful these procedures will be in improving neck and jawline definition without a lot of irregularities. This is also why the use of neck compression through circumferential garments (facelift bra) is important during the first week after surgery.

With any neck reshaping procedure, it is important to look at chin projection as well. Many full neck with an obtuse cervicomental angle have a weaker or poorly projecting chin. The use of a chin implant can make a dramatic improvement, in some cases as significant as the improvement in the neck angle. This ‘ying and yang’ approach, bringing the chin forward as the neck comes back, can have a very rejuvenating look to the neck.

While neck liposuction or a submentoplasty do not replace the need for a lower facelift, they can produce significant change in the right patient. Age (less than 50 years old) is one of the best indicators of whom these procedures work best in but not exclusively so.

Dr. Barry Eppley

Indianapolis, Indiana

Smartlipo of the Neck and Chin Augmentation – An Early Facial Rejuvenation Approach

Wednesday, June 23rd, 2010

The chin and neck angle relationship is one of the most significant facial markers that has a significant influence on the age of one’s appearance. A well defined chin point and a contoured neck angle are what most of us had in the first three to four decades of life. Aging changes the neck angle and, combined with even a slightly weaker chin, creates that loss of youth look.

The combination of neck liposuction and chin augmentation is one the most effective and relatively simple facial procedures. The best patients are generally under the age of 55 (average range 35 to 50 years old) who do not significant neck skin looseness or laxity. The neck skin may have some wrinkling and sun damage but one should not be able to pinch more than an inch of loose skin. (not bunching up fat, just loose skin) The key is patient selection for a good result. If significant loose skin exists, some form of a necklift (facelift) is needed.

Candidates for this combination often seek out or have already had non-surgical treatments like Thermage or SkinTyte. These minimally invasive neck and jowl treatments do not have the capability to really change facial contour. While they do create a minor amount of skin tightening and wrinkle reduction, they often leave patients disappointed. They are not capable of removing a double chin or a jowl sag.

For patients with a good chin profile, neck liposuction alone is all that is needed. I prefer the use of Smartlipo as it can be comfortably and effectively be done under local or sedation anesthesia. With Smartlipo, a 1mm fiber is threaded through a small stainless cannula for insertion under the neck skin. The cannula keeps the fiber from bending and breaking. The tip of the fiber sticks out beyond the cannula just a bit to deliver the heat energy to the fat. The fiber has an aiming beam so one can always see the laser point under the skin and know exactly where the laser is. The key to laser lipolysis is that it is performed with temperature monitoring so the neck tissues do not get too hot. The wavelengths of the laser has three beneficial effects. Its effect on hemoglobin seals off blood vessels which results in less bruising. The heat is very effective for breaking down and melting fat. Additionally, by heating the underside of the skin significant tissue tightening will result. While there is debate about how much skin tightening occurs after laser liposuction, it is fair to say that it is greater than that which is achieved by liposuction alone.

The recovery after Smartlipo of the neck is a maximum of ten days. Often it is within just a week. In some cases, the addition of simultaneous skin resurfacing can be done if there is any pre-existing wrinkles. This will not increase the recovery time at all as less than 50 micron depths are used.

The potential benefit of a chin implant with neck liposuction must be looked at carefully. Many neck contour changes can be enhanced by some more chin projection. Rarely does one need an implant of any significant size, 3 to 5mms of increased horizontal projection can be enough. With flexible silicone implants, they can be placed through the same under the chin incision used for neck liposuction, just slightly larger. Incision lengths less than 15mms are all that is needed.

For the right patient, Smartlipo of the neck with or without chin augmentation provides a very visible neck change, is cost effective, and does not have a long recovery.

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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