Hanging Neck Skin After Face and Necklift

Q: Dear Doctor,

I’m hoping you review this email and can give me a few ideas of what you think the situation may or may not possibly be.
I had my surgery on 5/5/2011, the underneath of the chin area is swollen but flat in the middle towards the neck. Its always looked like this except in the beginning it
was only slightly noticeable and now its getting worse and upsetting to view in the mirror.

From the sides it looks great… from the front, I see the center line tight, and on either side of that puffiness in what first appeared
to be swelling, however it has NOT gone away and I can only surmise that its the hanging skin effect of not being tightened up enough.

My neck lift was a huge job, entire surgery including full face, upper and lower eyes took 5 1/2 hours. Most of that time was spent on my neck. Liposuction under chin and full incisions on back of hairline, ears and temple area.

I was told it was my normal muscles under my chin, however I never saw that puffiness on either side years ago before facial aging. Nobody notices it, or at least won’t admit to it. I see it every time I look in mirror.

Its only six weeks since surgery. Ice packs used 24/7 for a few weeks to reduce swelling and for comfort. Compression garment worn 24/7 for a month.A m I expecting too much, too
soon? Why is the skin more puffy on either side of that flat, tight center muscle area that goes from chin to neck???

A: Hi ilenedream,

People who have a single muscle band or some excess fat under their chin are relatively easy to improve with a neck lift. People with a heavy neck or a significant amount of excess skin/wattle can pose more of a challenge. These patients may require a neck touch up 9-12 months after the initial procedure to get the best final result.

For the initial procedure, I think you surgeon was able to accomplish a lot of improvement in creating definition in the chin to neck angle where you did not have it initially. Your surgeon was able to remove a lot of the extra skin with this initial procedure.

Your questions why is it tight in the middle and hanging on the sides. It appears that liposuction was performed as well as a platysmaplasty to sew the edges of the platysma muscle together. The platysmaplasty sutures helps to define the chin area from the neck area and your surgeon accomplished this. The reason the center is flat is due to the platysmaplasty sutures. The sides that are hanging somewhat appear to be excess platsyma muscle.

There are two options to smooth out this excess. Either the surgeon can go back and “unzip” the platysmaplasty sutures and trim some of the excess muscle then resuture the cut edge of the platysma muscle back together. The other way to smooth out the excess platysma muscle is to redo the facelift and try to lift the SMAS upwards which is continuous with the platysma muscle. The difficulty with the latter solution is that patients who have a heavy neck tend to also have a heavy face and it is actually difficult to lift the heavy cheeks any higher than it was lifted during the initial facelift.

What you are doing by lifting your cheeks and jawline is the latter solution. Although you can make the hanging sides smoother by lifting the cheeks it can be hard to replicate using surgery what you can do with your fingers.

When we perform plastic surgery, the areas where we operate are typically injected with local anesthesia such as lidocaine (a cousin of novocaine). We inject these area to help minimize bleeding. The if the patient has a very thin “stringy neck” from muscle bands, it does take very much volume of local anesthesia to numb this patient’s neck, 15-20 cc’s or 3-4 teaspoons of local anesthesia may be enough to fully numb the area and minimize bleeding. For a patient with a full, heavy neck with more fat and skin, it may take more than double or even triple the amount of local anesthesia to properly numb the fat skin and tissuspes to minimize bleeding. These patients may already have 5-20 teaspoons more fat than the thin neck patient and on top of that another 8-12 teaspoons of local anesthesia is injected into the patients neck for the operation. After liposuction and the platysmaplasty these patient’s tissues are more swollen and thus more difficult to get a perfectly tailored neck. During the initial surgery the surgeon tries to remove as much skin as the face and neck lift will allow, but since the tissues were bigger to start with and more swollen from more local anesthetic injection fluid as well as the longer time it takes to operate on a heavy neck will also createmore swelling. These three factors all make the circumference of the patient’s neck bigger when it comes time to trim the skin. Yet we still need to be able to complete the operation by sewing the incisions closed. If we anticipate this and cut out extra skin, it may be nearly impossible to sew the incision closed and there will be a lot of tension of the incision which will lead to an ugly scar or the incision opening up after the sutures are removed.

When patients with a heavy face and neck come to me for a consultation, I ask them if they are at their ideal weight. If the patient wants to lose more than 15-20 lbs then I recommend that they lose the weight or as much weight as possible prior to going a head with a face and neck lift. If the patient can make their heavy neck into a thinner neck with muscle bands the chance for success with the initial surgery increases significantly. I have patient who I initially met for a consultation in 2007 who lost 50 lbs when I saw her again in 2009, but she was on a roll and wanted to lose another 15-20 lbs, so I advised her to keep going and come back when she reached her goal. I will be seeing her again this summer for a consultation and hopefully she has reached her goal and we can proceed with a face and neck lift four plus years after I initially met her.

On the flip side, I have a very nice patient with arthritis and bad joints who has never been able to lose much weight. She had both a heavy face, heavy jowls and a a heavy neck. Prior to surgery, we discussed weight loss, but she felt that it would never happen and she wanted to have the surgery completed prior to the birth of her grandchild. I agreed to surgery , but told her that she would most likely need a retightening of her neck 9-12 months afternher initial surgery. As I predicted she did need the touch up, but luckily she knew ahead of time that this would likely happen.
Her photos before and after the initial procedure as well as after her touch up (under local anesthesia with Valium in the office procedure room) are shown at the end of this other post. george-yang-doctor/wattle-returning-months-post-lift-t142519-15.html

Usually the surgeon does not charge another surgeon’s fee to perform the touch up, but the patient may pay for another operating room fee and for the anesthesia. If the surgeon has a procedure room and is comfortable operating on patients with local anesthesia , the touch up procedures are often not as involved as the original surgery. If your surgeon wants to repeat the same surgery again then a full operating room and anesthesia fee may be necessary to perform the touch up.


Dr. Yang