NECK AND NECK: MAKING SENSE OF SURGICAL AND NON-SURGICAL OPTIONS FOR REJUVENATION OF THE NECK

Apart from standing on your head, there are about a million things you can do to improve the appearance of an aging neck.  Some work better than others.  They range from creams and lotions to invasive surgical neck lift procedures that completely restore the youthful contours of the neck.  The reason there are so many options for neck rejuvenation is that it’s perceived to be such a big problem for men and women.  Not in your twenties and thirties, perhaps, but from about forty it starts to sag. Usually under the chin at first, and then it spreads like a stone dropped into a lake:  left unchecked it would continue to sag and deteriorate. But hey, this is 2020!  Modern science means we just have to call on the right doctor or device and hey presto, goodbye turkey neck, goodbye double chin, hello defined, sculpted, smooth beautifulness.  Here’s how.

WHAT'S GOING ON WITH MY NECK?

Good question. Simply put, you’re getting older—and that’s life.  If you’re reading this you’re probably not going to just accept that though, right? You want to know how to tighten it up a bit, get that angle back.  Understanding what’s right for you, though, requires us to delve a little deeper into what’s causing the issue in the first place.  Firstly, there are two types of aging in this area.  The first is when your neck is heavy: you have a fullness under the chin.  The second is when you have predominantly volume loss and it’s just loose skin for the most part.  Treatment options in both scenarios overlap, but if you have fullness then you might require a debulking or removal of some of the fat as well as tightening as part of your rejuvenation.  With aging comes an inevitable change in the quality of skin. The usual lack of sunscreen, smoking, and poor nutrition will accelerate this skin aging that includes loss of collagen and dysfunctional elastin fibres; like a spring coil that loses it’s elastic rebound over time. The skin appears loose, like paper.  

Ultraviolet light results in pigmentation and a mottled, blotchy discolouration called poikiloderma of Civatte.  Fine lines and wrinkles creep in and light reflects poorly.  And that’s just the skin!  Underneath the skin, fat either accumulates (aka. double chin) or shrivels up, unmasking the appearance of the deeper anatomy. The first muscle to encounter under the skin of the neck is the platysma, that paper-thin sheet that sticks out in sinewy bands when you grimace in disgust. Beneath platysma, a touch more fat, then more muscles, then glands, and finally the bones of the jaw.  Even the glands sag and the bones shrink and offer less support for the overlying structures. 

 The bottom line:  the aging neck is a multi-faceted process that involves changes in the skin and all of the underlying anatomic structures from muscle and fat to bone.  Thankfully, there’s a fix for everything.  Here’s the lowdown on some of your options that can give you back your neck. 

THE SHARP EDGE

Let’s start at the deep end—surgery.  Modern surgical techniques for neck rejuvenation provide sometimes dramatic, lasting effects that can transform a sagging aged neck into a beautiful, swan-like youthful one.  However, all surgical techniques are not the same, so you need to discuss with your surgeon the plan of action, what to expect with surgery, and the outcome1. 

For example, if you are older and have sagging in the middle, just under your chin, you’ll almost certainly require a bit of work from an incision under your chin (central approach), not just from the area near your ear (lateral approach).  A number of things can be done through an incision under your chin, and you don’t need to worry too much about the scar here because it should be pretty much hidden.   From the central approach, your surgeon can take a little fat out from above or below the muscle, tighten the turkey neck bands, enhance and sharpen the jawline definition by trimming away part of the salivary glands, and even shave down the deeper muscles2. This approach also allows your surgeon to position a chin implant if you have a weak chin.  In younger people with pretty good skin but just a slight hanging in this area, this central approach to neck lift might be all that’s required3. However, if there’s a bit more going on in the neck in general, with sagging and loose skin, then a lateral approach will be advised too. 

This approach is usually part of a facelift, with the incision trickling down around your ear lobe and behind your ear so the skin of the neck can be lifted and tightened.  Some surgeons use threads at the same time to support the lift and deepen the shadow under the jawline4.  Many others use fat grafting to add volume back to the jawline and chin.  Fat is considered precious by most surgeons, and a nice cushioning layer of fat left under the skin helps contribute to a result with youthful, smooth contours. 

Facelift results are often judged based on the contours and angles of the neck, so the neck is key to successful “facial” rejuvenation. It’s best to explore all your options with your surgeon and know what to expect during the recovery. The downtime usually involves having drains placed under the skin for a few days, bandages and head garments, and bruising. 

POCKET OF FAT

Let’s row back a bit from surgery.  Say you’re nowhere near considering major neck lift surgery but can’t stand that little pocket of fat under your chin.  The double chin, so to speak.  You’ve tried exercise, watched your diet—the usual.  It’s still there, and maybe you’re deleting pictures on social media because no matter what angle you seem to take, you can’t get that sharpness you’d like, particularly from the side profile. If the skin is tight, reducing the fat is possible without surgery5.  

One option is injection lipolysis, the name used to describe breaking down fat cells in a localised area using injections placed through the skin, directly into the fat6. In America, Kybella® is the only FDA-approved product used to reduce moderate to severe submental fullness, a.k.a. double-chin, using non-surgical means.  This product contains deoxycholic acid, something that physically breaks down fat cells. 

Non-surgical treatments like this sometimes require a few treatments to get the desired results.  Another option is freezing the fat!  Coolsculpting® is an FDA-cleared technology that works very differently.  It reduces the temperature of fat cells under the chin the point that they simply die—shrinking the area and improving the bulge considerably. Interestingly, heat can also kill the fat cells, so technologies like SculpSure® have embraced the power of lasers to “melt” the fat away without surgery. Radiofrequency technologies are also widely used to shrink fat cells and kick start the production of collagen in the skin and underlying tissues under the chin7.  Most of these non-invasive fat-busting treatments have minimal downtime, apart from a little redness or slight swelling for a short period of time. 

TIME MACHINES

What about the skin itself? When skin loosens in the neck, no amount of exercise is going to solve the problem.  Creams and lotions will do little to tighten things back up, either.  Science has made significant progress, however, when it comes to gadgets that stimulate collagen and lift skin without surgery.  Radiofrequency delivers energy that creates heat in the tissues.  Even more precise is focused ultrasound.  Used to blast kidney stones and burn brain lesions, microfocused ultrasound focuses heat into the deep layers of skin and even onto the underlying muscle. Each dot of heat burns and coagulates the tissues with precision, shrinking the loose skin much like a piece of bacon shrinks on a frying pan.  Ultherapy® was the first FDA-cleared microfocused ultrasound device to do this8.  These treatments are completely non-invasive.  Bypassing the skin so you can literally walk in and out. 

Unlike surgery though, expect to see results only after a few months.  Radiofrequency needling using machines like Morpheus8® and Intracel® are powerful tools that have the double-whammy collagen boosting effect of needles plus heat9.  Sounds painful?  Your aesthetic Provider is likely to make it pain-free using some form of numbing cream first. 

UNDER THE SKIN

Liposuction of the neck is frequently performed at the same time as a neck lift or facelift.  The fat is literally suctioned out through little tubes placed under the skin via small incisions near the ear and under the chin.  Newer forms of lipo have been introduced to enhance skin tightening—this is particularly useful when you want to both remove fullness as well as tighten skin in the neck.  Examples include VASER®, a form or ultrasound lipo that blasts fat and tightens skin using ultrasound probes.  Lasers such as SmartLipo®, CoolLipo® and LipoLite® are used to stimulate collagen and remove fat using laser fibres placed under the skin.  Radiofrequency, the same form of energy used for external, non-invasive skin tightening can also be used internally.  Internal radiofrequency or RF devices use small probes to heat the undersurface of the skin, constantly monitoring the temperature. 

Devices like ThermiTight® and FaceTite® are used to remove fat, tighten a sagging neck and define the jawline and are usually performed while you’re wide awake10,11.  The rationale for placing probes under the skin rather than heating from the outside is that higher temperatures can be reached safely directly to targeted tissues.  These intelligent devices usually alert the doctor when specific temperatures have been reached, and even cut off the power when it gets too toasty in order to avoid inadvertent burns or blisters.  The sweet spot is about 65 degrees Celsius.  Get to this temperature for a while and you set in train a process of neocollagenesis—new collagen formation, a recipe for tighter, smoother skin.  In an attempt to produce more dramatic, surgery-like result, some Providers use combination approaches:  needling, radiofrequency, and perhaps liposuction. Results depend on how you started out, though.  Don’t expect transformative, surgical results if you opt for non-surgical or minimally invasive treatments!  Some less invasive, combination approaches can deliver exceptional result though if you have minimal or moderate aging of the neck. 

THREAD LIFT

Imagine if you could just lift the neck with a few little strings?  Yup—that’s a thing, and it can be done12.  Various biocompatible threads have been used over the years with the promise of lifting the face, brows or neck without surgery.  In theory, anything that can provide an instant, effective lift without too much knife-wielding would seem like a good thing.  The neck is notoriously challenging, though, due to the complex interplay between the anatomy and how it ages.  No matter what type of thread or thread lift technique is used for neck lifting, it’s not the same as surgery and results generally don’t approach surgical results. Still, Providers who have considerable experience with thread lifts can deliver impressive results as part of face and neck rejuvenation.  Threads are made from either dissolvable substances, including polydioxanone (PDO) and poly-lactic acid, or permanent suture material like polypropylene.  Some threads have hook-like projections called barbs oriented along their length, some have tiny cones, like Silhouette Soft®.  Some techniques don’t require incisions at all—they’re simply injected in under the skin in order to stimulate collagen.  Other techniques employ various forms of anchoring, like little slings or hammocks.  As a general rule, younger patients do better with threads, whereas older patients or those with heavier necks are best suited to different methods. 

TOOLBOX FOR THE NECK

Injectables for aesthetics spare almost no part of the body, and the neck is no exception.  Even Botox® can be injected into the neck—for horizontal necklace lines and vertical neckbands that stick out (that’s actually muscle).  When the skin in the neck loses volume, it can be replaced with fillers, sometimes diluted to treat the large surface area evenly.  Mesotherapy is used to hydrate and stimulate skin in the neck.  This involves numerous droplets containing hyaluronic acid or other agents placed into the skin itself.  Lasers and light target the upper layers of skin to treat pigmentation and redness.  Peels are used to gently resurface and refresh the top layers of skin to clear sundamage and make skin glow.  Resurfacing the neck is done with caution to avoid complications, though.  Unlike the face, there are much fewer regenerative glands in the skin of the neck, so you can’t peel as aggressively in the neck area compared to the face. 

Facial aesthetics and facial rejuvenation really implies “face and neck” aesthetics and rejuvenation.  Without addressing the neck and making it as youthful and beautiful as the face, things can be out of kilter.  When rejuvenation in the face and neck are considered together, harmony prevails.  Surgical and non-surgical treatments for neck rejuvenation and enhancement address the skin, fat, different muscle layers, glands, and even the bones of the lower face that help drape the skin over the neck smoothly.  It can be mind-boggling when you’re met with so many options for a wrinkly or sagging neck.  Instead of picking a treatment, it’s a good idea to decide what you’re willing to undergo in terms of downtime and cost, as well as potential risks associated with the various options.  Discussing the options and expectations with your Provider is key.  Consider less invasive options if you can’t afford downtime or have only early signs of aging.  Think about combination treatments if you’re keen to see more obvious results but perhaps still want to avoid surgery.  If you want to see a transformative change in your neck, discuss a formal neck lift with your surgeon. No matter what you do, always chat with experts first—it’s your neck on the line!

References

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2. Neck Lift: Defining Anatomic Problems and Choosing Appropriate Treatment Strategies.  Marten T, Elyassnia D.Clin Plast Surg. 2018 Oct;45(4):455-484
3. Short Scar Neck Lift: Neck Lift Using a Submental Incision Only.  Marten T, Elyassnia D.Clin Plast Surg. 2018 Oct;45(4):585-600
4. Suture suspension platysmaplasty for neck rejuvenation revisited: technical fine points for improving outcomes. Giampapa V, Bitzos I, Ramirez O, Granick M.Aesthetic Plast Surg. 2005 Sep-Oct;29(5):341-50
5. Neck Contouring and Treatment of Submental Adiposity.  Thomas WW, Bloom JD.J Drugs Dermatol. 2017
6. Deoxycholic Acid for Submental Fullness and More: Real-World Experience With 202 Patients.  Humphrey S, Femmer P, Beleznay K, Carruthers JDA.Dermatol Surg. 2019 Apr;45(4):624-627
7. Evaluation of safety and efficacy of noninvasive radiofrequency technology for submental rejuvenation.  Park JH, Kim JI, Park HJ, Kim WS.Lasers Med Sci. 2016 Nov;31(8):1599-1605
8. Evaluation of Micro-Focused Ultrasound for Lifting and Tightening Neck Laxity. Baumann L, Zelickson B.J Drugs Dermatol. 2016 May 1;15(5):607-14
9. Radiofrequency Microneedling: Overview of Technology, Advantages, Differences in Devices, Studies, and Indications. Weiner SF.Facial Plast Surg Clin North Am. 2019 Aug;27(3):291-303.
10. Thermistor-controlled subdermal skin tightening for the aging face: Clinical outcomes and efficacy. Sanan A, Hjelm N, Tassone P, Krein H, Heffelfinger RN.Laryngoscope Investig Otolaryngol. 2018 Dec 20;4(1):18-23
11. Nonexcisional, minimally invasive rejuvenation of the neck. Mulholland RS.Clin Plast Surg. 2014 Jan;41(1):11-31
12. Suspension Threads. De Masi EC, De Masi FD, De Masi RD.Facial Plast Surg. 2016 Dec;32(6):662-663