Neck Liposuction, Neck Lift or Other Treatments: Which one do we choose?

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A Youthful appearing neck

Understanding the Youthful Neck & The Journey of Neck Rejuvenation

Most people can envision what they consider an aesthetically 'ideal' or youthful neck. This vision often translates to a sense of elegance, health, and vitality. But what specific features contribute to this perception?

Hallmarks of a Youthful Neck:

When we talk about a 'youthful' neck, we typically refer to a collection of desirable traits:

1. A Smooth and Defined Jawline: A crisp, well-defined demarcation between the face and neck, indicating taut skin and underlying tissues.

2. A Smooth Neck Contour: Graceful, unbroken lines without significant sagging, bulges, or irregularities.

3. Clear Definition Between Jaw and Neck: A distinct angle (cervicomental angle) between the underside of the chin and the front of the neck.

4. Absence of Fullness Under the Chin: No "double chin" or significant submental fat, allowing the natural neck structures to be appreciated.

5. Even Skin Tone and Texture: Skin that is free from significant sun damage, deep wrinkles, or prominent horizontal bands.

6. No Visible Muscle Bands: The vertical cords of the platysma muscle are not prominent at rest.

The Aging Neck: Understanding the Changes

As we age, the neck is often one of the first areas to show visible signs of the passing years. These changes are a complex interplay of intrinsic (genetic) and extrinsic (environmental) factors, with sun exposure being a primary environmental culprit. Other factors include gravity, lifestyle choices (like smoking), and weight fluctuations.

Here are some typical changes we observe as the neck ages:

1. Skin Loosening (Loss of Elasticity): The skin's supportive structures, collagen and elastin, break down over time. This leads to sagging, a loss of firmness, and the development of fine lines and wrinkles. This is often described as "crepey" skin.

2. Increased Submental Fat: Fatty tissue under the chin (the "double chin" area) can become more pronounced due to weight gain, genetics, or the descent of existing fat pads.

3. Visible Platysmal Bands: The platysma muscle, a broad sheet of muscle in the neck, can separate or its edges can thicken and protrude, creating noticeable vertical "bands" or cords, sometimes referred to as a "turkey neck."

4. Descent of Deeper Structures: Deeper structures within the neck, such as the salivary glands (submandibular glands) or digastric muscles, can begin to sag and become more visible as overlying tissues weaken, creating bulges or an irregular contour.

5. Horizontal Neck Lines: Often called "necklace lines," these creases can deepen with age due to repetitive movement and loss of skin elasticity.

Unveiling the Layers: The Anatomy of Your Neck

Many patients visit our Ottawa clinic concerned about a "double chin," a "turkey neck," or simply loose, sagging skin under their chin. To effectively address these concerns, it's crucial to understand the underlying anatomy of the submental (under the chin) and neck region.

The edges of the Platysma Muscle are seen as bands as we age

Supra-platysmal Fat

Think of the neck in distinct layers:

1. Layer 1 - The Skin: The outermost layer. Its quality (elasticity, thickness, sun damage) is a critical factor in treatment planning and predicting outcomes.

2. Layer 2 - Supra-Platysmal Fat (Subcutaneous Fat): This is the layer of fat located directly beneath the skin and above the platysma muscle. It's the fat you can typically pinch. In most individuals, there's usually no more than 10-20ml of fat in this area, though this can vary. This is the primary target for treatments like submental liposuction or fat-dissolving injections.

3. Layer 3 - The Platysma Muscle: A large, very thin, sheet-like muscle that extends from the collarbones up the neck and onto the lower face, contributing to facial expressions like frowning or pulling down the corners of the mouth. As we age, the edges of this muscle can become visible as "bands."

4. Layer 4 - Sub-Platysmal Fat: This is a deeper layer of fat located underneath the platysma muscle. It serves as a cushion for deeper neck structures. This fat is not typically addressed with liposuction and requires more invasive surgical techniques if it's a significant contributor to neck fullness.

5. Layer 5 – Deep Neck Structures: This layer includes the digastric muscles (small muscles under the chin involved in swallowing), the hyoid bone (a U-shaped bone in the front of the neck), and the salivary glands (particularly the submandibular glands located under the jaw).

Important Note on Treatment Targeting: Most non-surgical and minimally invasive treatments for neck rejuvenation primarily target Layers 1, 2, and sometimes influence Layer 3. More comprehensive surgical procedures, like a deep neck lift, can address issues within Layers 1 through 5, including repositioning or reducing prominent glands or tightening deeper muscles. However, interventions in Layer 5 are less common and carry specific considerations.

The Consultation: Evaluating and Assessing Your Neck

When a patient presents with concerns about their neck, a thorough evaluation is the first and most crucial step. This involves assessing three primary features: the skin quality, the amount and location of fatty tissue, and the appearance and tone of the platysma muscle, as well as the deeper structures.

• Evaluation of the Skin (Layer 1):

  • How We Assess: Visual inspection for texture, wrinkles, sun damage, and elasticity (e.g., the "snap test" – gently pinching and releasing the skin to see how quickly it returns to place).

  • Key Factors: Patient age, history of sun exposure, smoking history, and genetics significantly impact skin aging.

  • Ideal vs. Challenging: Tight, healthy, elastic skin is ideal. Loose, thin, crepey, or severely sun-damaged skin presents more challenges for certain treatments, as it may not redrape smoothly after volume reduction.

  • Sun Protection: I cannot stress enough the critical role of consistent sunscreen use and sun protection in preventing premature skin aging in the neck.

• Evaluation of the Submental Fat (Layer 2 - Supra-Platysmal Fat):

  • How We Assess: Visual assessment and palpation (feeling the area). The "pinch test" – gently pinching the fat between fingers – helps quantify the amount of superficial fat present and how much can potentially be removed.

  • Importance: Understanding the volume and distribution of this fat layer helps determine if liposuction, fat-dissolving injections, or surgical excision is appropriate.

• Evaluation of the Platysma Muscle (Layer 3):

  • How We Assess: Visual examination at rest and with animation (e.g., asking the patient to clench their jaw or say "eeee").

  • Youthful vs. Aged: In younger patients, the platysma muscle is typically flat, smooth, and not visible. With aging, laxity can develop, and the medial (inner) edges of the muscle can separate and protrude, forming visible "platysmal bands."

  • Significance: The presence and severity of platysmal banding often indicate the need for surgical intervention (platysmaplasty) to tighten and repair the muscle for optimal results. Non-surgical treatments typically do not address significant banding.

• Evaluation of the Deep Neck Fat (Layer 4 - Sub-Platysmal Fat):

  • How We Assess: This is more challenging to assess externally but can often be inferred based on the overall neck fullness that doesn't correspond solely to superficial fat or skin laxity. Sometimes, imaging may be used in complex cases.

  • Considerations: If a patient has significant deep neck fat, it's important to set realistic expectations, as this fat is not typically removed with standard liposuction and may require more specialized surgical approaches, or it may be a feature that cannot be fully addressed.

• Evaluation of the Deep Neck Structures (Layer 5):

  • How We Assess: Palpation for enlarged or ptotic (sagging) submandibular glands. Understanding the underlying skeletal structure (like the hyoid bone position) is also important.

  • Relevance: Prominent salivary glands can become more noticeable after overlying fat is removed or skin is tightened. Discussing this pre-operatively helps manage expectations. In some surgical cases, gland reduction or suspension can be performed.

Navigating Treatment Options: Finding Your Best Path

One of the most challenging yet critical aspects of neck rejuvenation is selecting the treatment—or combination of treatments—that will yield the best possible results with the lowest acceptable risk for the individual patient.

The Risk vs. Benefit Discussion:

When I make recommendations, I always aim to balance the potential benefits of a procedure against its potential risks and downtime. This is a deeply personal decision. Some patients are willing to accept more potential risks or a longer recovery for more dramatic or definitive results. Key questions I encourage patients to consider are:

• "Is a marginal (e.g., 5%) increase in potential aesthetic improvement worth a significantly higher (e.g., 20%) increase in risk or downtime?"

• "What level of improvement do I need to see to justify undergoing a more invasive procedure?"

It's vital to remember that all procedures, whether surgical, injectable, or energy-based, carry some level of risk. A thorough understanding of this balance, tailored to your personal priorities, is essential for making an informed choice you'll be happy with.

Surgeons have several methods for improving a patient's neck. We can categorize these options based on the primary layers they target:

1. Skin Care & Topical Treatments — Layer 1 Focus

• Mechanism: High-quality skincare products aim to improve the health, texture, and appearance of the skin itself.

• Details: This includes:

  • Sunscreen (SPF 30+ daily): The single most important preventative measure.

  • Retinoids: Promote cell turnover, stimulate collagen, and improve skin texture and fine lines.

  • Antioxidants (Vitamin C, Vitamin E, Ferulic Acid): Protect against environmental damage and can brighten skin.

  • Peptides & Growth Factors: Support collagen production and skin repair.

  • Hyaluronic Acid Products: Provide hydration and can temporarily plump fine lines.

• Benefits: Improves overall skin quality, can address mild texture issues and fine lines, minimal risk. An excellent foundational approach for all patients.

• Limitations: Will not address significant sagging, deep fat deposits, or prominent muscle bands. Results are gradual.

• Ideal For: All patients as a baseline; those with very early signs of aging or seeking to maintain results from other procedures.

2. Skin Tightening Lasers & Energy-Based Devices — Layer 1 (and sometimes Layer 2) Focus

• Mechanism: These technologies use various forms of energy (laser, radiofrequency, ultrasound) to deliver controlled heat to the skin and sometimes the superficial fat layer. This heat stimulates collagen and elastin production, leading to gradual skin tightening and improved firmness.

• Examples: Radiofrequency (RF) treatments, microneedling with RF, focused ultrasound, certain laser resurfacing treatments.

• Benefits: Can produce noticeable skin tightening and texture improvement with minimal to no downtime for many devices. Can be a good option for those not ready or able to undergo surgery.

• Limitations: Results are typically more subtle than surgery and may require multiple sessions. Not effective for significant skin excess, deep fat, or prominent muscle bands. Patient selection is key.

• Ideal Patients for This Treatment:

  1. Younger patients with mild to moderate skin laxity and good underlying skin quality.

  2. Patients who desire improvement but are unwilling or unable to undergo surgery.

  3. Patients seeking to maintain results from previous surgical procedures.

  4. Those with realistic expectations about the degree of improvement.

  3. Dermal Fillers — Primarily Layer 1 (can subtly affect Layers 2, 4, 5 by adding volume/definition)

• Mechanism: Injectable gels, typically hyaluronic acid-based, are used to restore volume, enhance contours, or stimulate collagen.

• Techniques & Benefits:

  1. Traditional Volumizing/Contouring: Fillers can be strategically injected along the jawline to enhance definition and create a sharper angle, camouflaging early jowling. This adds volume and structure.

  2. Biostimulatory/Skin Boosting: Diluted hyaluronic acid fillers or other biostimulatory agents can be injected superficially under the skin. This doesn't add significant volume but hydrates deeply and creates a controlled inflammatory response that stimulates the body to produce new collagen (neocollagenesis) over time, leading to improved skin texture, elasticity, and subtle tightening.

• Limitations: Results are temporary (typically 1-2 years, depending on the product and area). Not suitable for significant skin laxity or major volume issues. Potential for bruising, swelling.

• Appropriate Patients for Dermal Fillers:

  1. Mild to moderate aging of the neck and jawline.

  2. Good to fair skin quality.

  3. Desire a quick result with limited downtime and lower initial risk.

  4. Understand the limitations and have realistic expectations for subtle to moderate, temporary improvements.

  5. May be used to refine jawline definition or address specific hollows.
     

4. Chin Implants — Affects Layers 1 (by skin tension) and 5 (by altering skeletal projection)

• Mechanism: A biocompatible implant (commonly silicone) is surgically placed over the chin bone to enhance its projection and definition.

• Benefits: Can dramatically improve the jawline and cervicomental angle, thereby improving the appearance of the neck by increasing skin tension and reducing the appearance of loose skin under the chin. Can balance facial proportions.

• Limitations: Surgical procedure with associated risks (infection, malposition, nerve irritation, dislike of implant feel). Does not directly address significant fat or platysmal bands.

• Appropriate Patients for Chin Implants:

  1. Have a recessed or "weak" chin (microgenia).

  2. Mild to moderate loose skin under the chin that can be improved by increased skeletal support.

  3. Minimal to moderate fat under the chin (or may be combined with liposuction).

  4. Willing to accept the risks and recovery associated with a surgical implant.

5. Liposuction (Submental Liposuction) — Primarily Layers 1 and 2

• Mechanism: Excess supra-platysmal fat (Layer 2) is removed through small, discreet incisions using a thin tube called a cannula. The healing process can also induce some skin tightening (Layer 1).

• Benefits: Can dramatically improve the neck contour by reducing a "double chin" and defining the jawline. Relatively quick recovery compared to a full neck lift. Minimal scarring.

• Limitations: Does not address significant skin laxity (skin must have good elasticity to retract), platysmal bands, or issues with deeper neck structures.

• Appropriate Patients for Submental Liposuction:

  1. Moderate to excellent skin quality and elasticity.

  2. Identifiable excess fat in the supra-platysmal layer.

  3. Mild or no significant platysmal banding.

  4. Mild to moderate loose skin under the neck that is expected to retract.

  5. If platysmal banding is present, they understand liposuction alone will not correct it.

  6. Understand and accept the risks associated with liposuction (e.g., bruising, swelling, temporary numbness, contour irregularities).

6. Surgical Neck Lifting (Cervicoplasty / Platysmaplasty / Deep Neck Lift) — Addresses Layers 1, 2, & 3 (and potentially 4 & 5 in deeper lifts)

• Mechanism: This is the most comprehensive approach. Incisions are typically made around the ears and sometimes under the chin.

  • Excess skin (Layer 1) is removed and redraped.

  • Excess fat (Layer 2) can be directly excised or sculpted.

  • The platysma muscle (Layer 3) is often tightened and sutured together in the midline (platysmaplasty) to correct banding and redefine the neck angle.

  • In a "deep neck lift," work may also be done on sub-platysmal fat (Layer 4) and occasionally prominent digastric muscles or submandibular glands (Layer 5).

• Benefits: Can produce the most dramatic and long-lasting improvements for moderate to severe neck aging, addressing skin laxity, fat deposits, and muscle banding comprehensively.

• Limitations: Most invasive option with the longest recovery time, more significant downtime, and higher potential risks (e.g., hematoma, nerve injury, infection, unfavorable scarring). Scars are longer, though typically well-hidden.

• Appropriate Patients for Neck Lifting:

  1. Moderate to significant loose skin under the chin and neck.

  2. Variable skin elasticity (can be performed even with poorer elasticity, though results may differ).

  3. Obvious or significant platysmal banding.

  4. May have excess fat in superficial or deeper layers.

  5. Are healthy individuals who can safely undergo surgery.

  6. Accept the risks, recovery period, and scarring associated with the surgery.

  7. Are willing to accept the extended downtime.