Falling Necks, Pixies Ears, & Thick Neck Scars

Dr. Yang Explains… Why necks fall after a face/necklift, Pixie ears, and Thickened scars behind the ears

Why do these things happen after a facelift?
Do surgeons who perform facelifts intentionally get these problems? Of course not. We all try to do the best that we can, based on what we were trained to do, and based on our prior experience. Why do some surgeons tend to get these problems repeatedly. Either they don’t perform enough facelifts to see a pattern of problems, or they don’t look carefully at how the ears turn out so they are oblivious to the fact that they are having this problem, or they just don’t care. For example, I don’t want any of my patients to walk around with a residual turkey neck, pixie ears or not be able to have their hair up because of bad scarring behind the ears. I don’t get very many of them anymore, but if I see it I will immediately offer to repair it. The surgeons that get the fewest facelift problems are also the same ones that will admit to it and offer to fix it. It’s a matter of pride in the work that you do. I don’t want any of my patients to have signs of a facelift.

History of the facelifts, pixie ears and altered hairlines.
Facelift patients in the past knew that their ears and hairlines would be permanently altered which explains the special hairstyles which hide the front of the ears and the large ear rings that cover the earlobes which would hide any pixie ear appearance. It was so commonplace that surgeons that perform facelifts would explain to the patient that this is just how it the results turn out, and would they rather have a looser facelift over a better looking ear. Why compromise? Dr. Bruce Connell, the father of the post-modern facelift, did not like the problems that the traditional facelifts created, and modified facelift techniques in order to minimize obvious facelift “give aways”, pixie ears, loss of sideburn hair, change in hairline, altering of the cartilage in front of the ear. http://www.realself.com/blog/avoid_bad_facelift.html

Even though Dr. Connell has lectured and explained in great detail how to avoid these problems, how come these things still happen. Just because a surgeon can perform a facelift doesn’t mean that they are good at it, just as you, your brother or sister, or husband may be a golfer, but that doesn’t mean that you are a professional golfer or even a single digit handicap golfer. The best golf coaches in the world are giving tips to amateur golfers on TV, golf magazines, on-line yet the majority of people who play golf just don’t improve very much. It is the rare golfer that is able to absorb all the tips and information and implement it into their golf game and continue to improve. This can be said about surgery in general. The difference between other surgery and plastic surgery is that the results are out there for the world to see, whereas if one surgeon sews together the intestines more meticulously than another surgeon, no one will know about it since all the nice work is hidden inside.

Why Does it Happen?
(Disclaimer: These statements are purely based on my experience and observations)
Relaxation, Rebound or “Snap-back” Phenomenon
For the necklift, this is the result that plastic surgeons want to deliver for their patients.

So how do we achieve this? There are two ways to accomplish this. The obvious way is to pull the skin below the earlobes back behind the ears. Many people who are self conscious about their aging necks actually do this in the mirror.to simulate what it would look like to have a younger neck. The second way is a corset platysmaplasty which will be described later in this thread The basic facelift procedure actually tightens the muscle below the earlobe, to the back of the ear. This occurs with both SMAS facelifts and deep plane facelifts. In these photos, I drew out the fibers of the the neck muscle called the platysma. On the left is how the fibers of the platysma muscle naturally exist in our body. On the right you can see how the back edge of the platysma muscle is lifted and tacked to the back of the ear with the “blue” stitches. You can see how the muscle bands would be pulled backwards and become hidden with this type of necklift.

What I want everyone to see is how the fibers of this muscle (platysma muscle) is pulled back, which helps to smooth the muscle bands on the front of the neck. What I believe happens (at least in my experience) is that muscle fibers like to be in a straight line, and by anchoring the muscle behind the ear, the muscle does not like to be in this position, and many patients with a SMAS lift will describe a strong pulling/tugging sensation behind their ears which goes away in 6-8 weeks, while other patients who may have had a deep-plane repositioning of the platysma muscle may take six months to a couple of years for that that tight feeling behind the ears to go away. The blue arrow represents the direction of the platysma repositioning in the necklift, while the yellow arrow represents the tendency for the muscle to “snap-back” or rebound into a more natural anatomic position (straight line) of the platysma muscle.

Imagine the platysma as a muscle at no thicker than 2 frozen Philly cheesesteak slices. If you placed 2-4 fishing lines sutures through a muscle that thin, eventually the threads will cut through this thin muscle.

This is the order that I also perform my face and necklift. Other surgeons will perform the facelift on the sides of the face and if they still see some left over muscle bands, then they will decide whether or not they will perform the corset platysmaplasty. The problem is that you almost never see any muscle bands after putting in the stitches behind the ears; therefore these surgeons rarely do a corset platysmaplasty as their necklift. If you don’t have at least a 1/2″-1″ incision under your chin this procedure was not done with your facelift.

Image Credit: Rejuvenation of the Aging Neck, Sykes, JM, Facial plast Surg 2001; 17: 099-108, Thieme-connect.

These are the surgeons who may not understand the value of the corset platysmaplasty or may not feel as comfortable with the anatomy under the chin and finding the edges of the platysma muscle. Why would I make such a bold statement? Because when I first started out in my practice, I fit in this category of surgeons. As I became more proficient at platysmaplasties, I could find the platysma muscle much more quickly and create a nice clean edge of platysma to sew to. Initially, I did not like doing platysmaplasties because of a concern for bleeding deep in the neck and controlling the bleeding if it were to happen through 1/2″ incision. Instead they try to perform the necklift from the sides of the face and behind the ear. This does improve the neck, but it is a less effective necklift as compared to necklifts performed by the panel of facelift experts. (Again, I was one of these surgeons early on, and these opinions are based on my own early experience and attitude towards corset platysmaplasties.) In fact, if a necklift fails after pulling from the sides only, many times the surgeon knows exactly what to do in order to get rid of the muscle bands, which is a corset platysmaplasty. If this is the case, why wasn’t it performed in the first place?

Now, I love doing platysmaplasties, because I think that a properly performed necklift is the foundation for an excellent facelift result. I think that whether or not a corset platysmaplasty is performed may possibly be even more important than the choice of the type of facelift: deep plane versus SMAS facelift. If there were two patients getting a face and necklift both with turkey neck/muscle bands, and one patient was getting a deep-plane facelift without any neck liposuction or corset platysmaplasty, versus the second patient who was getting a SMAS facelift with neck lipo and corset platysmaplasty, I would bet that the second patient would actually get a better overall lift than the deep-plane facelift without a formal necklift.

A corset platysmaplasty sews together the free edge of platysma muscle under the chin to create a small hammock or sling which supports the flat area under the chin and creates a neck/chin angle (cervicomental angle.) An advanced maneuver to prevent thick muscle cords from reappearing, is to cut the edge of the platysma muscle at the neck/chin angle about 1/2″-1″ to prevent the muscle from tenting through the skin in the future.

Neck Liposuction.

Image Credit: http://www.bellevueplasticsurgeons.com/
Note: that there was no facelift or mini-facelift involved with this improvement, and that there is no incisions around the ear.

Submentoplasty (a corset platysmaplasty from an incision under the chin, without incisions behind or around the ears.

If I can get the neck profile to look like this with a corset platysmaplasty alone, is it really necessary to tack the SMAS/platysma behind the ears to get an excellent necklift, or does it actually cause more problems further down the line? (i.e. Pixie Ears and Thicken Scars behind the ears)

Here is another Necklift (corset platysmaplasty with excess skin removed from behind the ears) with a extended SMAS facelift performed under local anesthesia only.

Finally, if you haven’t already seen Barbara’s earlobes and post-auricular incision enough times in the past, here it is again. Now you understand the thought that went behind making this incision and earlobe the way that it looks after surgery.

To summarize, I believe the the problems of falling necks, recurrence of neck muscle bands, pixie ears, and thickened scars behind the ear are related to trying to perform a necklift by solely tacking the back edge of the platysma muscle behind the ear without first performing a corset platysmaplasty.

Happy Thanksgiving Everyone.