The neck wattle is a common sign of facial aging and often one of the most bothersome. Even in the presence of many other facial changes that occur with time, some patients find the sagging neck to be the first and, sometimes only, area they want addressed. This is particularly seen in older men.
While a facelift is the traditional approach to the neck wattle, there are numerous reasons why some patients do not want to undergo that operation. Cost, recovery, and lack of hair or a good hairline in and around the ear are the most common.
An alternative approach to neck wattle reduction is the direct necklift. While uncommonly done, this operation removes the neck wattle by cutting it out right down the middle of the neck. A small but powerful operation, excess skin and fat are removed and the platysmal separation sewed together…directly. While there are a lot of advantages to the direct neck lift (minimal recovery, short operative time, little to no bruising or swelling), it comes with the trade-off of an unnatural location for the resultant scar. Patients must balance that disadvantage with its other advantages.
To help with that determination, an appreciation of the scar in the direct necklift is critical. The ultimate question is…how does the scar look and is it a bad scar? The scar pattern is really an H-shape that is turned on its side. A small horizontal limb is right under the chin (hidden and is inconsequential), a longer vertical limb that runs between the underside of the chin and a low horizontal skin crease (the scar concern) and a low horizontal scar just under the thyroid cartilage. (adam’s apple, that usually heals imperceptibly in older thin skin)
I have used three types of direct necklift incisional approaches. They differ in how the vertical scar line is placed. The vertical scar can be a straight line, a straight line with a central Z in it (z-plasty), and a running W-pattern. The purpose of the breaking up the straight line with a Z or a lot of W cuts is to prevent scar contracture and tightening at the cervicomental angle. I have seen good scar results with all of them and this probably has a lot to do with patient selection. (older male patients 60 years and up) Currently, I favor the straight line approach for the vertical scar and will usually defer the need for a central z-plasty until later. In some cases, but not all, a hypertrophic scar will develop in the tightest part of the closure (cervicomental angle) with the straight line closure. Depending upon how the closure feels during surgery, a z-plasty may be placed if it is felt to be advantageous and this is usually done in women as opposed to men.
For the well-informed patient, a direct necklift can be a better operation for their neck wattle. The scar does particularly well in men because of their beard skin, daily microdermabrasion treatments that they do (shaving) and the value of a re-established sharp cervicomental angle when wearing shirts. Its value in women lies in its simplicity and minimal recovery, particularly in the face of older age and comproming medical conditions.
Dr. Barry Eppley
Indianapolis, Indiana