As one’s face ages, there is a gradual downward shifting of tissues from the cheek down into the neck area. The combination of time, gravity, and loss of skin’s elasticity and its underlying anchoring ligaments accounts for this inferior movement. Because the jaw (mandible) acts like a ‘fixed fence line’, the falling over of aging tissues creates the appearance of jowling and loss of a once sharp neck-jaw line angle.
But beyond the jawline, other well seen areas are also affected by this tissue migration. Down at the ‘bottom of the well’, the lowest area of the neck can also accumulate excess or rolls of loose skin. These can become particularly evident in patients over 60 years of age and are one of the late signs of facial aging. Just above the sternal notch at the levels of the low end of the thyroid cartilage and across the level of the cricoid cartilages, loose aged skin folds up onto itself extending outward into the sides of the neck. Folds may often hang over into the concave sternal notch area.
While facelift surgery can produce remarkable changes in the central and upper portions of the neck across the jaw line, it does not usually provide significant improvement in the low central neck. This is a simple function of the mechanics of how a facelift works. The greatest impact of tissue movement from a facelift comes from areas closest to where the upward pull is coming from…the ear. As you move further away from the ear, the influence of the pull becomes less. The lowest portions of the central neck are as far as you can get from the ear area and are affected by a facelift little if any at all.
The most powerful procedure to change the bothersome loose rolls of skin in the lower neck is a sternal notch tuck-up or a low horizontal neck lift. Removing skin directly can make a dramatic difference. Using a visible low horizontal neck skin crease that commonly runs across this area, the skin excision uses that line to orient the placement of the final scar. This is a very simple skin excision procedure that often can be done under local anesthesia. There is no swelling, pain and usually little to no bruising afterwards. Dissolveable sutures are placed under the skin so suture removal is not needed.
The sternal notch tuck-up can remove as much as one to two inches of skin which is overlying the low central neck area. This gets rid of that telltale sign of aging which is hard to hide. Even after an excellent facelift result, this area can still not be substantially changed when all the swelling has subsided. Like the appearance of the back of the hands, loose and sagging low neck skin can give away one’s age regardless of how well the jawline and upper face looks.
When should a sternal notch tuck-up be considered? It is a procedure that should not be done at the same time as a facelift. This is not only for vascular and healing considerations but also because a full facelift may well provide enough improvement in this area that the need for it may be unnecessary. It could, however, be done at the same time as a limited or mini-facelift (aka Lifestyle Lift) because neck skin flaps are not raised to any significant degree in this procedure. Liposuction is usually the only procedure done in the central neck area with this type of facelifting.
Ideally, a sternal notch tuckup is done after a facelift has demonstrated that this area is not adequately improved. The thin aged skin of the lower neck typically heals so well that the scar that is created is negligible.
Dr. Barry Eppley
Indianapolis, Indiana