While facelift surgery has many variations in technique in its objective in most patients it is a neck-jowl lifting procedure. There are numerous deeper tissue manipulations (SMAS and deep plane) but a major component of the procedure is the location, or more importantly, the extent of the incisions used to perform the procedure. In the end excess/loose face and neck skin is removed and this plays a major part in the outcome of the surgery.
The posterior part of the typical facelift incision as it wraps around the earlobe lies in the postauricular crease of the ear and then tails into or along the occipital hairline. This part of the facelift incision controls neck skin redraping completely and the jawline skin redrawing partially. The occipital hairline part of the incision typically does not need to go lower than the level off the earlobe in most patients. (many do not even need to go that low)
But when a lot of loose neck skin exists this level of the occipital hairline incision may be inadequate. When kept at this level the neck skin may end up inadequately addressed and an unnatural superior line of neck skin pull may be seen behind the ear. This patient is a good example of that phenomenon even though the level of the occipital hairline incision is fairly low. As she aged from her initial facelift the redundant neck skin become even more apparent centrally as well as the unusual looking pulled skin look behind the ear.
The only way to improve the neck, both centrally and posteriorly, in this situation is a much longer and lower occipital hairline incision. The choice is either to make it along the hairline with an exposed scar line or back cut it into the hair and have a visible occipital hairline step off. That choice depends on the patient’s hair density and style as well as which aesthetic liability they prefer. In either case that goal is to work out the excessive neck skin and change the vector of the neck skin movement for a less obvious line of pull.
By lowering the occipital hairline incision a large amount of neck skin can be relocated and removed. In some cases, as in this patient, that is easily an inch or more of neck skin removed on each side below the ear level. Almost as equally important is that vector neck pull is more horizontal rather than vertical.
The obvious aesthetic tradeoff is the more visible hairline incision/scar. in this patient the two occipital hairline scars almost met in ythe middle of the posterior neck. But depending on the hair length and style this may be more aresthetically acceptable than the loose creepy neck skin.