Neck lift

This article covers corrections directed at the neck skin, the platysma and the submental tissues, the choice of method, how the operation relates to a face lift, recovery, scars and risks.

What is a neck lift?

A neck lift is an operation that addresses looseness of the neck skin, the bands formed by the superficial muscle known as the platysma, and fullness under the chin. The aim is to shape the transition from beneath the chin to the neck in a way that suits the person's anatomy. The procedures performed on skin, muscle and fat carry separate aims.¹

Not all of the fullness under the chin is made up of fat beneath the skin. Fat under the platysma, the anterior belly of the digastric muscle and the submandibular salivary gland are also structures that can affect the appearance.² For that reason the same surgical plan may not suit two necks that look similar from outside.

A neck lift and a face lift are most often performed in the same session. This article covers the neck skin, the platysma, the neck angle and the submental area. Corrections directed at the cheek and lower face tissues are the subject of the face lift article. That distinction does not mean a face lift has no effect on the neck. The SMAS in the face and the platysma in the neck are continuous structures; which areas an operation extends to is not determined by the name of the incision alone.³

Who is it suitable for?

A neck lift can be considered in people with looseness of the neck skin, marked muscle bands or fullness under the chin. What matters in the selection is not age alone but which tissue creates the appearance and the state of the skin.¹ The area you want changed and the area the operation can affect are expected to overlap at the examination.

In selected people whose skin quality is suitable and whose fullness is limited to superficial fat, liposuction alone can be considered. Where there is a marked platysma problem, excess skin or a contribution from the deeper tissues, removing superficial fat alone may not meet the same aims.¹ Choosing a wider operation is not decided simply by wanting more change.

General health, previous operations and the ability to manage care during the recovery period are assessed together. Where there is an active infection or an uncontrolled illness, those are addressed first. If the expected change, the scars and the risks are not acceptable to the person, not having surgery is also an option.

What does the examination look at?

Skin and jawline: The looseness and elasticity of the skin, where the excess lies, and how sagging along the jawline relates to the neck are examined. Sagging in the face and changes belonging to the neck alone are recorded separately.

Platysma and bands: The medial edges of the muscle and the bands visible at rest and on movement are assessed. Whether the looseness is the same in the middle of the neck as at the sides is established. That examination helps in choosing between medial and lateral procedures.

Superficial and deep fullness: Fat beneath the skin, fat under the platysma, the digastric muscle and the submandibular gland are assessed separately. The submandibular gland is the salivary gland lying beneath the lower jaw. Assessing the deeper structures does not mean they will be reduced in everyone.

The hyoid and the neck angle: The hyoid is the bone to which the muscles of the tongue and neck attach. Its position is taken into account when the transition between the submental area and the neck is assessed.² Changing the position of the hyoid is not an aim in this practice; it is considered as an anatomical limit on what the result can be. That does not mean the position of the bone cannot be altered by any surgical method.

A study based on 282 computed tomography scans assesses the position of the hyoid anatomically; it is not a surgical outcome study measuring the neck angle achieved by an operation.⁴ How many degrees of correction one person will obtain cannot be calculated from that data.

Sensation, movement and previous procedures: Lower lip movement, the differences present between the two sides at the outset and any existing numbness are recorded. Previous facial or neck operations, liposuction, fillers and energy-based treatments should be declared. Medication, supplements and nicotine products used are part of the assessment.

At the end of the examination it is settled which tissues will be operated on, where the incisions will be, whether a face lift will be added, and which features are not expected to change. Reducing fullness in one area and correcting sagging in another are not the same decision.

How is the operation planned?

Is the neck addressed alone, or together with the face?

Aims for the neck and aims relating to the cheek and jawline are set separately. Where there is marked sagging of the face, a procedure on the neck alone may not meet the whole change at the transition between face and neck.¹ Adding a face lift is decided on that assessment; the detail of the SMAS and deep plane methods stays in the face lift article.

For the transition from the cheek to the lower eyelid a midface lift, and for the outer brow and temple a temporal lift, carry separate aims. Planning a neck operation does not mean those procedures will also be performed. Where procedures are combined, the scope and the care plan are arranged accordingly.

Can liposuction alone be enough?

Liposuction alone is one of the methods used, in selected people. The aim is to reduce the superficial fat beneath the skin. How well the skin will redrape, and at what depth the fullness lies, matter in the selection.¹

Liposuction is not the same procedure as repairing the platysma with sutures in the midline, suspending it from the sides, or removing excess skin. Fullness arising from deep fat, muscle or gland should not be treated as though it were superficial fat. Which structure is addressed is determined by examination.

Is the platysma addressed in the midline or from the sides?

Medial platysmaplasty: The platysma is adjusted with sutures in the midline of the neck. Where needed, transection of the muscle or removal of part of it is also performed. It should not be assumed that every medial repair involves the same amount of muscle transection.

Lateral platysma suspension: The platysma is moved and fixed from the side. The position and looseness of the tissue at the side of the neck are part of that decision. Medial repair and lateral suspension can also be used together.

Midline repair and moving tissue from the sides are different adjustments.¹ The choice is made according to the distribution of the bands and the looseness. It is not stated that one of these methods is sufficient on its own for every person, or superior to the other.

Where is the incision made and how is excess skin addressed?

The incisions are made beneath the chin and behind the ear. The length of the incision and how much of each part is used are determined by the planned correction. Submental access allows the muscle and fat to be addressed; redraping the skin and removing any excess are planned separately.⁵

The submental incision, that is the incision beneath the chin, is a route of access. Making that incision does not show that the same muscle or gland procedure is performed in every patient. Correction directed at the skin is likewise assessed separately from adjustment of the deeper tissues.

Closure is done with sutures; behind the ear staples, that is surgical clips, may also be used. Wound closure strips are applied to the areas operated on. The purpose and the removal time of the closure sutures differ from those of the temporary hemostatic net sutures.

Is a procedure needed on the deep fat, muscle or glands?

Fat under the platysma, the digastric muscle and the submandibular gland are the deep structures assessed in this practice. Where the examination shows that the structure in question contributes to the fullness, a procedure can be planned in selected people. Reducing deep fat, adjusting the muscle and reducing the gland are not procedures that substitute for one another.

Removing part of the submandibular gland is a separate surgical procedure requiring careful assessment of the deep anatomy of the neck and the surrounding structures.⁶ Gland reduction is not a step performed in everyone. The expected contribution has to be weighed together with risks such as bleeding, nerve involvement and collection of saliva.⁷

Seeing or feeling a structure at examination does not by itself mean that structure will be removed. Which structure will be addressed, and why, is explained before surgery.

How are the drain, dressing and garment planned?

A drain is used in selected patients; it is not a routine step. A dressing is used until discharge, and a compression garment is provided on discharge. The timing of drain removal and how and for how long the garment is worn are determined by the findings at check-up.

A drain, a dressing and a garment do not do the same job. The extent of the operation and the findings in the early period are assessed together. Using them does not remove the need to keep increasing swelling or pain under review.

Why is the hemostatic net used?

The hemostatic net is a technique in which temporary sutures passed through the skin close the potential space between the skin and the tissues beneath it. The aim is to eliminate the space in which a haematoma, that is a collection of blood, could gather. In this practice it is applied to the area operated on; it is not a step that every surgeon applies or that is compulsory in every neck lift. These sutures are removed at the clinic after 2 to 3 days.

In a meta-analysis of 8 studies and 1,617 patients covering face, brow and neck rejuvenation surgery, pooled rates of 0.14 per 100 observations were reported for haematoma and 12.70 per 100 for red suture marks.⁸ These are single-arm pooled results from groups in which the net was applied; they are not a comparison with a group without the net, nor a rate belonging to neck lifts alone. It cannot be concluded from that data that a drain is unnecessary.

Removing the net sutures and the fading of the temporary marks on the skin are separate processes. How the marks develop is explained in the section on scars.

How do you prepare for surgery?

Smoking and nicotine: Smoking is a risk factor for wound healing problems after surgery. Direct surgical data on nicotine products other than cigarettes are scarcer. The practice reference of the American Society of Plastic Surgeons notes a lack of clinical data on e-cigarette use and surgical risk, but states that because nicotine is known to reduce blood flow, e-cigarettes and other nicotine products are regarded as a potential risk factor.⁹ Stopping smoking, vaping and other nicotine-containing products at least 1 month before the operation, and not using them after surgery until healing is complete, is therefore advised. The studies below concern smoking cessation; their results do not establish the same reduction in risk for every nicotine product. A review pooling 6 randomised and 15 observational studies showed that every week of abstinence added benefit, and that studies with at least 4 weeks of abstinence produced markedly better results than shorter ones.¹⁰ A study appraising systematic reviews together reported that cessation interventions beginning at least 4 weeks before surgery and combining multiple behavioural support sessions with pharmacotherapy reduced complications. The same study notes that interventions with only one component, even when started more than 4 weeks before surgery, raise quit rates without reducing complications.¹¹ Shorter intervals are not useless either: in a meta-analysis of 55 studies covering adults undergoing a range of operations, the risk of pulmonary complications was 27 per cent lower in relative terms among those who stopped at least 2 weeks before surgery, and 29 per cent lower among those who stopped at least 4 weeks before, compared with those who continued smoking.¹² The benefit therefore grows as the interval lengthens; being late does not make stopping pointless. The interval applied and the nicotine policy can vary from surgeon to surgeon.

Coexisting illness: Diabetes and blood pressure are expected to be under control before surgery. Where there is an active infection in the body, surgery is postponed.

Medication: Blood thinners and some herbal products can increase bleeding. Every medicine and supplement you take needs to be declared. Prescribed medication should not be stopped on your own decision.

Tests and anaesthetic assessment: The tests required are determined by general health and by the anaesthetic assessment.¹³ Any previous problem with anaesthesia or drug allergy should be declared. The instructions given about fasting and about how to take medication on the day of surgery are followed.

Home and transport: Someone is arranged to accompany you home on discharge.¹³ The timing of check-ups, the help you may need in the first days and the plan for time off work are organised beforehand. Follow the surgical team's guidance on preparing the operation area; do not shave or prepare the incision area at home on your own initiative.

What is recovery like?

The operation is carried out under general anaesthesia. 2-3 hours are planned for the operation and 1-2 nights for the hospital stay. The summary box covers both a neck lift alone and a neck lift performed together with a face lift. Where a face lift is added the periods can lengthen; the overall surgical plan is set for each person. The detail of the facial technique is the subject of the face lift article.

The first check-up is in the first week. For the hemostatic net sutures, a separate clinic assessment and removal of the sutures are planned after 2 to 3 days. For the other stitches, the 1 week given in the summary box is a short figure; they are removed within 7 to 10 days, with the incision checked. The staples behind the ear are assessed at the same check-up.

Bruising is expected to settle over 7-10 days and marked swelling over 2 weeks. These intervals do not mean everyone reaches the same appearance on the same day. Being fit to return to work can come before all the bruising and swelling has gone.

The shape becomes possible to assess over 2-3 months, while residual mild swelling can last up to 3-4 months. Assessing the shape therefore does not mean that all swelling has finished by that day. The direction of healing is monitored at check-ups; swelling that increases, is painful or is markedly one-sided is not explained by recovery time alone.

Mild difficulty in swallowing and a feeling of tightness in the neck are among the findings expected in the early period. Their reaching a degree that obstructs breathing or swallowing is not regarded as ordinary and calls for urgent assessment. A rapidly expanding collection of blood in the neck is reported to be able to affect the airway.⁷ In that situation the next scheduled check-up is not waited for.

What to pay attention to after surgery

The following is a general framework. Where the instructions you were given differ, your surgeon's instructions apply.

Dressing, garment and drain: A dressing is used until discharge; a compression garment is provided on discharge. How the garment is worn and for how long are determined by your surgeon's instructions. A drain is not routine; it is used in selected patients. Where a drain is present, its care and the timing of its removal are arranged according to the findings at check-up; it is not removed on your own. Carrying out dressing and drain care according to the instructions given to you is advised after a neck lift.¹⁴

The incision and strips: The care instructions given for the sutures and strips beneath the chin and behind the ear are followed. The creases of the ear and the area behind the ear are not rubbed, and crusts are not picked off. Guidance from the surgical team is taken before changing the strips or applying any product around the incision. Movements that rub the submental incision line and the area behind the ear are avoided.

Sleeping: Rest with the head elevated. Your surgeon decides how long that position and the avoidance of physical strain are continued. A sleeping position that puts no pressure on the incision is preferred. Returning to sleeping on the side or front is assessed according to the state of the incision and the swelling.

Cold application: Cold is applied to the operated area without pressing on it. The form and duration of the application are determined by your surgeon's instructions.

Showering, wound and dressings: When you may shower depends on the dressing used. If there is a skin incision, once allowed you can shower without rubbing the wound and pat the area dry gently. Baths, swimming pools and the sea wait until the wound has closed completely.

Washing your face: Washing the face is allowed within 3 to 7 days, after the incision and dressing have been checked. Which day and how to begin are determined by your surgeon's assessment. The instructions given for the wound closure strips and the hemostatic net sutures are followed.

Shaving and make-up: These begin after 2 weeks, at your surgeon's decision. Applications that rub the incision line or carry product onto an area that has not yet healed are avoided. The interval passing does not by itself mean it is suitable.

Movement: Strain such as bending the head down, straining and heavy lifting is limited in the early period. Movements that stretch or rub the incision area are avoided. Even if you feel well, do not return to strenuous activity suddenly. Activity and rest through the day are organised according to the plan given on discharge.

Pain: There may be tenderness, tightness and pain in the neck, beneath the chin and behind the ear.¹⁵ The painkillers provided are used as instructed. Pain that keeps increasing, becomes marked on one side in particular, or comes with increasing swelling of the neck should not be watched and waited out. The surgical team is told if a new painkiller or additional medicine is to be used.

Returning to work and sport: 2 weeks are set aside for returning to desk work; in physically demanding jobs healing is assessed separately. Return to sport is staged from 4 weeks. It begins with light activity; the surgeon's approval is awaited for movements that keep the head down for long periods, that require straining, or that carry a risk of impact to the operated area. The 6 weeks given for a full return to daily life does not mean the scar has also finished maturing.

Driving: A return to driving can be assessed after 1 week. The effects of the anaesthetic on attention and reflexes must have passed, and there must be no visual problem, dizziness or use of painkillers that cause drowsiness. You should be able to turn your head, follow the traffic comfortably and perform sudden manoeuvres without pain. Where those conditions are not met, no one drives even if the interval has passed. On discharge you go home accompanied.

Sexual activity: A return can be assessed once everyday movements no longer cause marked pain and you feel comfortable. Pressure on the head and neck, movements that stretch the incision line, and marked straining are avoided. Rather than a fixed day, the course of healing and the surgeon's advice are taken as the guide.

Smoking: Smoking impairs wound healing after surgery as well; cigarettes and nicotine products should be avoided until healing is complete.

Findings that are normal: Swelling, bruising, tenderness and tightness in the neck, beneath the chin and around the ear, and numbness or altered feeling around the incision, can occur.¹⁵ What matters is less the presence of a mild finding than how it changes. Swelling that increases rather than settling, pain that progresses, or a new loss of movement should not be judged as ordinary healing. Mild difficulty in swallowing and a situation that obstructs breathing or swallowing should not be confused with one another.

How do the scars change?

How are the scars beneath the chin and behind the ear followed?

Neck lift incisions leave scars. The incision lying beneath the chin or behind the ear does not mean there is no scar. A conspicuous scar is among the reported risks of a neck lift.¹⁵

Maturing of the scar is expected to take between 6 months and 1 year. An incision line that looks red, firm or more prominent early on is assessed over that period. The final appearance of the scar is not settled on how it looks at the first check-up.

Silicone gel, silicone sheeting and massage are advised for the scar beneath the chin. Silicone gel, silicone sheeting and massage are advised for the scars in front of and behind the ear. When they are begun and how they are applied are determined by the surgeon according to how the incision is healing. For the scalp scar, silicone gel, silicone sheeting and massage are not advised. The same care is not applied to every incision area.

The incisions for this neck operation are beneath the chin and behind the ear. The distinction in care relating to the area in front of the ear or the scalp applies where a procedure performed at the same time, such as a face lift, involves an incision in that area. It should not be assumed that these additional incisions are made in every neck lift.

The plan given by the surgeon is followed for care of the incision. Care is taken to protect the area from the sun. Where there is wound separation, discharge or increasing tenderness, it is not treated as merely part of the scar maturing; assessment is requested.

When do the marks from the hemostatic net sutures fade?

The marks at the entry points of the hemostatic net sutures are different from the incision scar beneath the chin and behind the ear. In the Ribeiro meta-analysis covering facial, brow and neck procedures, red marks were reported to resolve completely within 2 to 3 months and not to progress to persistent darkening of the colour.⁸ That result does not mean the skin will look free of marks on the day the sutures are removed, or that the risk of a lasting mark is zero in any one person.

Temporary redness and a newly developing wound problem are not treated as the same thing. Where the marks increase, or discharge or pain accompanies them, the care plan is reassessed.

Risks and complications

Risks are assessed according to the extent of the procedure performed and the person's situation. Removing superficial fat alone and operating on the platysma, the deep fat, the muscle and the glands are not the same surgical scope.

In a review of 12 publications and 2,106 patients covering neck operations involving transection of the platysma, recurrence of platysma bands was reported at 1.4 per cent, nerve damage at 0.9 per cent, haematoma at 1.8 per cent and sialoma, that is a collection of saliva, at 0.3 per cent.¹⁶ These are rates pooled from different studies. They are not separate risk rates for liposuction alone or for each medial and lateral technique; the follow-up conditions of the studies likewise cannot be turned into a single personal risk timetable.

Problems of shape, symmetry and scarring

A difference remaining between the two sides, surface irregularity, a conspicuous scar or the appearance not meeting expectations are possible.¹⁵ Early swelling and a difference remaining after healing are assessed separately.

Further correction can be considered for residual looseness or bands that become marked again.¹ The decision is not made simply because there is a difference in appearance; how that difference relates to skin, muscle, fat, the scar or the anatomy present at the outset is established.

Where an incision extends into the scalp in a combined procedure, temporary or permanent hair loss can develop around it.¹⁵ That possibility does not mean a neck operation performed only through incisions beneath the chin and behind the ear involves a scalp incision in everyone.

Problems of sensation and lower lip movement

Sensation: Numbness or altered feeling on touch can develop around the ear and near the incision. The great auricular nerve carries sensation from the earlobe and the area around it; it is different from the facial nerve that works the muscles of expression.³ Feeling and movement are assessed separately at check-ups.

The facial nerve: The marginal mandibular branch relates to lower lip movement and the cervical branch to the platysma. These branches matter in work in the neck region.³ A newly developing difference or weakness in lower lip movement should be assessed without delay. The 0.9 per cent above is not the rate for these two branches separately, nor for permanent damage alone.¹⁶

In a selected series of 641 people in whom deep neck procedures were performed together with a face lift, temporary involvement of the marginal mandibular nerve was reported in 21 people, and all of these findings were stated to have resolved within 6 months.⁷ That is not the rate for a neck lift alone, nor a guarantee of recovery in the same time in every person.

Problems of bleeding, the wound and fluid collection

Bleeding and haematoma: A collection of blood in the operated area can cause swelling and tightness. An expanding haematoma in the deep neck can affect the airway and may call for urgent surgical assessment.⁷ Where there is rapidly increasing swelling of the neck, steadily more severe pain, or anything obstructing breathing or swallowing, the scheduled check-up is not waited for.

Infection and the wound: Infection, delayed healing of the wound and tissue loss can develop.¹⁵ Where redness spreads, or there is discharge, fever or separation of the incision edges, assessment by the surgeon is needed. Prevention of infection and treatment where needed are decided according to the person's situation; there is no single medication plan for everyone.

Seroma: Tissue fluid can collect in the operated area and may need draining by the surgeon.⁷ A new swelling cannot be distinguished as blood or tissue fluid without examination. Do not press on the area yourself or try to drain the fluid.

Collection of saliva: Particularly where the scope involves a procedure on the salivary gland, a collection of saliva in the operated area is assessed separately.⁷ That is not the same as a seroma. The 0.3 per cent in the review should not be read as a separate rate for all gland reductions.¹⁶ Where there is new swelling or discharge around the gland, examination is needed.

Anaesthetic and general surgical risks

Risks relating to general anaesthesia are considered together with the medical history and the anaesthetic assessment. General surgical risks such as cardiac and respiratory problems are also part of the assessment.¹⁵

Blood clots: A clot forming in the leg veins and travelling to the lungs is serious. One-sided leg pain and swelling, sudden shortness of breath or chest pain need urgent assessment.

The approach to preventing clots is decided according to the person's risk and the operation planned. The measures to be used are explained in the discharge and care plan. No blood thinner is started without being prescribed, and existing treatment is not altered on the person's own decision.

Risks relating to added procedures

Where a face lift or another facial procedure is added, the risks and care requirements of that procedure are assessed as well. In a series of combined operations it is not possible to attribute every problem that develops to the neck procedure alone. The results relating to deep structure surgery in particular should be read together with which additional procedures were performed.⁷ The whole plan is explained before surgery.

Can the neck angle and the platysma bands change again over time?

Improvement in the neck angle and the appearance of the muscle bands are not the same measure of outcome. The result can change over time; it cannot be said from the number of years alone that further surgery will be needed.

In the study by Jones and Lo assessing 50 people 5.5 years after their first face lift, 69 per cent of the correction achieved in the neck angle was reported to have relapsed. In the same people, 21 per cent of the elevation achieved in the sagging tissues of the jawline had relapsed.¹⁷ That series is not a series of neck lifts alone. The 69 per cent does not mean that 69 per cent of patients had a recurrence; it describes how much of the correction obtained at the outset had returned.

That finding shows that, in the same series, the neck and the jawline followed different courses over time. In the overall appearance scoring, 76 per cent of people were reported still to look younger 5.5 years later than they had before surgery.¹⁷ That assessment is not the result for the neck alone, nor a percentage of patient satisfaction. Partial relapse of the correction in the neck angle does not mean the whole result of the operation has been lost.

The 1.4 per cent for recurrence of platysma bands is the pooled result of neck procedures involving muscle transection.¹⁶ Because it does not measure the same thing as Jones's loss of correction in the neck angle, the two percentages are not compared directly. The follow-up times in the research are not presented as a promise of durability or as a timetable for further surgery.

What can be expected from the result?

The aim is to shape the transition from beneath the chin to the neck by assessing the neck skin, the muscle bands and the tissues contributing to the fullness together. Not every structure needs a procedure. The examination explains which change is intended and which anatomical features will be preserved.

The neck angle does not depend only on the amount of fat removed; the deeper tissues and the position of the hyoid also need to be included in the assessment.² No promise is made that everyone will obtain the same sharply defined angle or a completely symmetrical appearance. The scope of correction in one area does not show that there is no need in another.

Assessing the shape, returning to daily life and the maturing of the scar are not completed on the same date. Decreasing swelling in the early period, the balance of the two sides, lower lip movement, sensation and the appearance of the incision are monitored together at check-ups. Decisions about the result are made according to how this process develops.

When should you contact a doctor?

Do not wait for the scheduled check-up in the following situations:

• Rapidly increasing swelling and tightness in the neck or beneath the chin
• Swelling or difficulty in swallowing reaching a degree that obstructs breathing or swallowing
• Pain that increases rather than settling, or becomes marked despite the pain treatment given
• Fever, spreading redness or discharge from the incision line
• Separation of the wound or bleeding that does not stop
• New marked pallor, darkening or blistering of the skin
• New loss of lower lip movement or a marked difference in movement
• Pain, pressure or swelling increasing under the dressing or garment

A rapidly expanding haematoma in the neck can affect the airway.⁷ Where breathing or swallowing is obstructed, urgent assessment should not be delayed while trying to reach the surgeon. Mild difficulty in swallowing being an expected finding does not mean that a worsening problem should be waited out at home.

One-sided leg pain and swelling, sudden shortness of breath or chest pain are also emergencies. Where there is a sudden breathing problem in particular, urgent assessment is not delayed.

About the numbers in this article

The intervals given for the operation, the hospital stay, stitch removal, returning to work and activity, and for bruising, swelling, the shape settling and the scar maturing are a framework of clinical practice. The summary box covers both a neck lift alone and a neck lift performed together with a face lift. The removal time of the net sutures is separate from that of the other stitches.

The rates in the research are pooled from different studies and different surgical scopes. A rate reported for procedures involving transection of the platysma is not the rate for liposuction alone, and a series of combined face and neck operations is not the result of a neck lift alone.

Loss of correction measured at long-term follow-up does not mean that the same proportion of patients had a recurrence. The follow-up period is not presented as a promise of durability or as a timetable for further surgery.

The studies on stopping smoking cover different operations. The relative risk reductions in those studies do not amount to a complication rate specific to a neck lift, or to separately proven effects for every nicotine product.

References

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