An aesthetically pleasing neck has a number of criteria, which were initially defined by Ellenbogen and Karlin27:
- ■ Distinct inferior border of the mandible
- ■ Subhyoid depression with visible thyroid cartilage
- ■ Visible anterior border of the sternocleidomastoid muscle with 90° angle with the submental line
- ■ Cervicomental angle between 105° and 120°.
The important characteristics include an acute cervicomental angle of 105–120°, a visible anterior border of the sternocleidomastoid muscle, and a distinct inferior border of the mandible27. A youthful neck is slim and one should always consider the girth or the circumference of the neck as additional criteria during assessment. The girth of the neck is often not referred to as a criterion in the majority of references. The main cause of an increase in volume of the neck is the result of fat deposition. Recontouring the cervicomental angle is an important goal in neck lift surgery and removing the adipose tissue is essential to achieve this target. When the fat is removed the girth of the neck is also reduced.
Surgical rejuvenation of the neck is suitable for patients with volume and/or skin excess in this region. After a thorough clinical evaluation and investigation, the following points should be considered for surgical intervention:
- ■ Characteristics of the skin
- ■ Distribution of fat in the submandibular region and volume excess in the neck
- ■ Bony structures
- ■ Need for additional procedures, chin and jaw.
The important landmarks include the relationship between the chin, jaw line and the neck. A number of systems have been developed in the past to classify the neck, and treatment protocol can be selected accordingly. Age-related change to the cervicomental angle has been described by Dedo5 (Table 1). This classification, taking account of all the elements of the neck and skin changes, is grouped into six sub-types. A similar system by Baker6 defines four sub-types based on changes related to the neck and jowl areas (Table 2).
This is generally a minimally-invasive procedure, which aims to lift ptosis of the neck associated with the ageing process. Thread lifts are performed using bioabsorbable cones and non-absorbable sutures placed in the subcutaneous plane. The threads help to maintain the position during the healing process, and the cones are absorbed by the body.
A neck lift using the threads can be suitable for patients with early jowl formation, with mild-to-moderate skin laxity and platysmal bands. The treatment can also be considered for patients who wish to avoid major surgical procedures and for minor adjustment following surgery. A thread lift can be carried out as an outpatient procedure under local anaesthesia and sedation. The entry points are placed in the post-auricular region and sometimes limited liposcuplture can be performed at the same time to attain superior results. The result of a thread lift is temporary and often the patient requires repeat or additional procedures to counteract the effects of ageing. There are many varieties of thread lifts with different techniques available to perform neck lifts. These include Aptos threads, Isse Endo Progressive Facelift Suture®, and contour threads. The contour thread consists of non-absorbable nylon suture and projecting barbs angled in one direction. The threads are introduced in the opposite direction of the barb and when pulled, will be anchored to the tissues. Aptos subdermal suspension threads have biodegradable barbs in variable lengths. The ends of the sutures are anchored in the dermis28–32.
Liposculpture can be used to contour the neck, and the techniques include conventional, laser, ultrasound and RF-assisted methods. The ideal patient for such procedures is young (usually aged mid-40s and younger, but also dependent on skin type, gender and ethnicity), with mild-to-moderate submental adiposity and good skin tone. Liposuction is often carried out via submental and lateral approaches. Cannulae are available in a range of sizes suitable for liposuction of the face and neck. The technology not only provides efficient management of volume excess, but also provides tightening of the skin. Liposuction alone has a limited value in treating subplatysmal
fat, which often requires open excision in conjunction with neck lift33–36.
Open neck lipectomy and cervicoplasty
The technique of cervicoplasty follows a sequence of steps that can be adapted and modified for patients of any age group:
- ■ Supraplatysmal contouring by the direct excision of fat, and liposuction via the submental approach
- ■ The platysma on either side is elevated and fat in the subplatysmal plane is removed. In some patients there is a strip of fat at the inter-platysmal area contributing to the fullness of the neck
- ■ Submandibular glands on either side are dissected at the subcapsular plane, and the gland is excised and flushed, with the lower border of the mandible
- ■ Digastric contouring is done by shaving the anterior muscle and in some cases, direct plication is carried out
- ■ Corset platysmaplasty to redefine the cervicomental angle and transverse myotomy is carried out at two levels
- ■ Liposuction, lateral platysmal suspension and skin tightening via the periauricular approach is carried out in selected cases and redundant skin is excised. Some of these patients also need lateral platysmal suspension in order to recontour the lateral neck
- ■ Additional procedures such as chin and jaw augmentation is justified in some cases (Figure 3).
Excisional lipectomy and submentoplasty with a number of modifications have been described in the literature37–39. The key steps in the approach include submental dissection lipectomy, and platysmaplasty. The approach to different layers of the neck and removal of excess fat in the relevant planes is an integral part of the contouring process40–42.
Restoration of the neck and décolletage has a vital role in total facial rejuvenation. Management can be broadly classified into surgical and non-surgical methods. Non-surgical approaches have a significant, but limited role in the rejuvenation process, and surgical interventions provide long-lasting results. Appropriate selection of treatment modalities suitable to address the patient’s concerns is the cornerstone of a successful outcome. Application of multimodal rejuvenation techniques will help to achieve better cosmetic outcomes and higher patient satisfaction.