Saving Your Neck: Neck Lifts, Explained

SPEAKER_01 0:00

In general, um, women are much more attuned to facial aging than men are. And that and I think anatomically it's much different too. In general, if you look at the craniofacial dynamics of women versus men, men have have wider jaws, they have thicker bone on the lower portion of the mandible, and that lends itself to less jowling, I believe. In women, mandibles are thinner, they're they're less wide, um, there's less projection many times, and that unfortunately lends itself to a lot of jowling. And I think if you attempt to tighten up just the neck only, um, you're gonna leave some redundancy of skin in the jowls, which looks like an overdone look. I want to welcome everyone to our next Beauty and the Beast podcast. I'm, of course, Dr. Sal Pachella from San Diego, California. And I'm here with my good friend and fantastic surgeon, Dr. Sam Jajar from Dallas, Texas. How are you today, my friend?

SPEAKER_00 0:59

Doing great. Just happy to be here.

SPEAKER_01 1:01

All right. Well, we're gonna talk about a great concept today, a great topic that's gaining a lot of popularity, and it's about neck aging.

SPEAKER_00 1:09

So you're saying neck aging is becoming popular?

SPEAKER_01 1:12

The topic of rejuvenating the neck is neck is becoming popular. I think we're we all experience neck. I mean, I see a little uh, yeah. All right, perfect. So um, so Sam, tell me a little bit about in your practice, um, are patients asking for their necks to be tighter? What what what do you see patients coming in to ask for?

SPEAKER_00 1:32

Yeah, neck, neck lifts, neck tightening procedures are really exploding in popularity, like you were alluding to. It is actually one area of facial rejuvenation where I see as many men for uh for cosmetic consultants as I do women, because I think it's an area that we all start to notice changes. So, you know, it's interesting though, because when someone comes in saying they want their neck looked at or their neck tightened, they could be talking about a lot of different things. So when you're evaluating someone's neck, what are the things you're looking for? And how does that sort of influence what procedure you might have them do?

SPEAKER_01 2:06

That's a great question. And I think there are major components to understanding anatomically what is aging, what is dropping, and what is the best procedure to go after each of those. So the first concept is really the skin. Okay. And I think part and parcel for anyone who has um neck laxity, the skin is loose, and that just goes along with aging. Okay. And so the simple concept of supporting the skin by excising it and doing a necklift or lower facelift, that that's kind of a gimme. Okay. Uh gimme in in the sense of excising and tightening the skin in a general way. Okay.

SPEAKER_02 2:41

Okay.

SPEAKER_01 2:42

Um, now, it I know you're you're gonna be telling me all about some different techniques that you use in the office, in the med spa, okay, um, which I'm I may not disagree. I may disagree with. Okay, so let's go, let's go to that for a second. Let's go off of that topic for a second. So the second component is the fat of the neck. Okay. A lot of patients that come in, they say, Oh, look at this thickness to my neck here. And that that's a subcutaneous fat problem. And I think surgically and non-surgically, that can be dealt with in multiple different ways. The third component, I think we have to understand, is the muscle layer of the neck, the platisma layer. That's the area of structure of the neck, okay? And that's what non-surgical treatments don't treat very well. Um, and so when we're talking about a deep plane facelift or a deep plane neck lift, those are the things that are really tightened up. Now, to take it one step further, there's another layer to the neck that I think we're getting much more aggressive in because we're understanding the anatomy further. And that layer is related to the glands of the neck. Okay, and a little bit of a controversial topic in plastic surgery. And those of us that do deep neck surgery. And so things like excising the submandibular glands, excising the muscles of the neck, uh, these are concepts that I think are really, really important to understand. And as a surgeon, you have to tailor your effect to that. So let's go back to the topic of skin. Okay, so a little bit of controversy between us. So tell me about in your practice, how you deal with the skin non-surgically.

SPEAKER_00 4:16

Um, where the skin is concerned, non-surgically, the only real options that we have at this moment in time to tighten the skin are radio frequency technology. And this has gone through a few iterations. We had in the beginning what was called bipolar technology, where basically we were delivering radio frequency technology from one lead to another from a probe. And those are technologies that people have heard of, like FaceTite or Morpheus 8, which is the same company as FaceTite, which is um microneedling and radio frequency, or softwave. Um those are technologies that were really exciting when they first came out. Um, softwave in particular in our practice, when it first came out, we were using it a lot. And um notice I'm speaking in the past tense because there are some problems with um with any sort of radio frequency treatment. The first is you get an initial tightening that is so impressive, right? If you heat anything, if you are, you know, using um, I don't know, uh like you're burning yourself, you'll notice there's an initial tightening that happens. But that initial tightening is short-lived and is oftentimes related to the inflammatory process that's actually there. And so there's some relaxation that occurs. Um, the results a few weeks later may not match. Now, we tell people that there's ongoing collagen deposition that happens, and it does. Um, but you know, it really depends on someone's ability to form collagen. So a 25-year-old patient who's got lots of fat in their neck, and we'll see why I'm mentioning that in a second, is going to be a great candidate for radiofrequency because they're gonna likely have pretty good skin elasticity, though not always. A 55-year-old patient who's got relatively poor skin elasticity and not a lot of fat in their neck is gonna be a terrible candidate for it. Because what we've realized is these radiofrequency technologies will actually cause atrophying of the underlying fat. And so there's actually a black box warning with things like Morpheus ache, where you can actually develop uh facial fat loss from them. So you have to be careful. And the worst case scenario is not that the treatment doesn't work well. The worst case scenario, and I've seen several patients in this category, um, is that it actually creates a problem that wasn't there before, which is atrophying of lower facial fat if you're treating the neck.

SPEAKER_01 6:42

So you're saying patients with some skin elasticity, with a bit of subcutaneous fat, actually do very well with these radio frequency techniques.

SPEAKER_00 6:51

They can do well. A young patient who's got good skin elasticity and and of and fat loss wouldn't be the end of the world. That's that's your candidate for it. Okay. Now there's some newer monopolar radio frequency technologies that are getting some traction. The biggest one right now is Zerf, um, which um is really popular because Kim Kardashian just came out and said that it was like the latest and greatest thing. And she is known to be an expert in radio frequency technology. And so what she's saying obviously should carry a lot of weight. She's an expert in a lot of things. Yeah. Um, and I'm sure she wasn't paid for that endorsement at all. But um, but um, and right now that's sort of the latest thing that's getting a lot of buzz. Who knows? Maybe it's real, there's just no long-term studies. So, not as controversial as you think. I think that um it's worth touching on radio frequency because there are huge moneymakers for med spas, for surgical practices that are out there. But you know, ultimately they do tend to be overused. So that's skin. Um, let's talk about fat. I'm gonna say a word to you and just free association. Kaibella.

SPEAKER_01 7:54

My free association is uh so you know, kybella uh was a very popular um fat dissolver, I think that came out probably a good 10 years ago, maybe. Yeah. And so, you know, worked really well initially, I think. It was highly marketed and injecting and indicated for the uh submental areas of fat. And I think it it, like many things, it kind of got very popular and then lost a lot of um activity afterwards. I think it it tends to overcorrect things. Um, it tends to cause a lot of rippling, a lot of deformities. And there's a sweet spot of injection that you have to really be adept at. And so, you know, I never really had it widely adopted in my practice. Tell me a little bit about you and what you've used it for.

SPEAKER_00 8:46

I haven't used it in 10 years, probably, but it's an interesting story. And I and I don't know people that actively use it a lot at this point, but I see patients not infrequently that have come in that have been disappointed by their chibella. So it's deoxycolic acid, which doctors will know is bile, basically. So it it's basically you're injecting a purified version of bile underneath your um underneath your skin to dissolve the fat. It's so disgusting. So and it creates it creates a massive inflammatory response. And so um, I've had it done twice as a as a patient back in the day, years ago. The the first time it worked, okay. So then the second time it was right before my 45th birthday, probably a week before that. And it looked, it worked okay. And then I got on a uh transatlantic flight and flew to Paris. And when I landed in Paris, I literally looked like that Martin Short character where like his neck was all swollen. Like it was insane how much the inflammatory reaction was. And actually, that inflammation was so significant, I think it actually promoted more skin laxity than I had had before. Wow. Um generally, I think the experience with Kybella, in my experience, is patients are profoundly disappointed. They need four to six treatments usually to get a result that, if they're lucky, might equate to what a simple in-office life dissection procedure was.

SPEAKER_01 10:04

Let me just say, as a plastic surgeon and your friend, I think you have to, you gotta, you gotta hold off on any of these plastic surgery treatments below the nasal line. You know, we talked about your lip and maybe you want to temper that a little bit.

SPEAKER_00 10:18

Noted, noted. I'm not sure I'm gonna follow that, but I but I welcome your opinion. Um the the next thing to talk about is banding, blitzma bands. We had talked about muscle. Any non-surgical treatments that you think might be useful for that?

SPEAKER_01 10:34

Um, you know, occasionally um in the right patient, I may inject a neuromodulator or Botox into those areas. And it's really just simply for patients that don't like the banding, that don't want to do anything significant. And I think Botox and neuromodulators can work reasonably well for just tempering those bands. They're not going to go away. Um, but particularly I like to inject them right near right up above the sternum mostly, um, because I think that's where the tightening and the tension really is. And that that works to some extent, I think.

SPEAKER_00 11:04

And then glands. You talked about glands, and now we're sort of coming into the surgical world. And you'd mentioned that it was potentially a hot button topic of wrong plastic surgery. Why is that?

SPEAKER_01 11:15

Well, so um so if you just if you kind of look at somebody's neck, and you know, common thing we do in plastic surgery is when we take photographs, we take them at various angles. But one of the more popular photographs we take is this flex neck appearance like this. And you can see a lot of times when people do that, or when patients do that, you can see a couple little lumps on the side of the neckline right here. Those are the submandibular glands, those are anatomic salivary glands that secrete uh saliva into the mouth. There are some pretty large blood vessels running in and around that site. And so um so years ago, uh, and I think there's there's been a resurgence of this, uh, particularly related to some surgeons. Uh, there's a fantastic and very careful surgeon, Francisco Bravo in in Spain, who does a tremendous amount of this, does it very safely, and has really great results. Um, but I think, and a lot of surgeons dabble in this, and I think it's it's a challenge. Um, so these types of techniques, when you're removing these glands, it's done usually through the neck incision. We're tightening up the platisma bands or resecting them, but then you have to go a layer deeper. There are there's a layer of muscle there called the digastric muscles. There's an anterior band and a posterior band. Sometimes in deep neck rejuvenation, those bands are removed. And that's, think about that, you're removing a muscle of the neck cosmetically, you know. Another little layer deeper to that, off to the side, is where those submandibular glands are. And surgeons sometimes remove the whole gland, sometimes they remove parts of the gland, sometimes they fry the gland with a with a cautery uh device to shrink it. Um, I do know that trying to reposition the brand the gland up into a higher position is usually not something that is really reliable. Okay. And I will say in my practice, I sparingly remove or resect a part of the submandibular gland. I never really completely remove it. I may just take a section of it off to prevent prominence. And this is absolutely something I always discuss ahead of time with the patients because, you know, there is there's a risk reward to everything. And in deep neck surgery, that risk is huge. You know, if you damage one of those nerves or have a secondary hematoma afterwards, it can be a devastating complication.

SPEAKER_00 13:42

Yeah. And I think that's probably the, I mean, I probably do it in about 5% of patients.

SPEAKER_01 13:46

And most patients would say, I don't want to take that risk. You know, and I think as long as they're okay with having a little bit of a bulge on the side of their neck, you know, hardly noticeable, I think it's a safe move.

SPEAKER_00 13:57

And sometimes you wonder how much of the things that plastic surgeons do are things that plastic surgeons notice and that the patients don't actually notice. In a salivary gland that is has slight prominence, most people wouldn't think actually makes them look any older. And, you know, if when you tighten the superficial muscular structure or the platisma muscle, you know, if you're able to make it snug, you're probably going to make them look like they did when they were younger, which is going to make most of your patients pretty happy. Right. You know, um, because very few of my patients come to me and say, I want to look like somebody else. They say, I want to look like I did a few years ago.

unknown 14:31

Right.

SPEAKER_00 14:32

So um one thing that is a hot button term, and you use it a couple times, is deep plane necklift. What is a deep plane necklift? Because it's not a defined thing in plastic surgery, but it's everywhere on social media. Right, right.

SPEAKER_01 14:48

And so I think it's an all-encompassing term a lot of times, okay. And part of this is quite honestly marketing, right? Um, there's some surgeons that have developed this term that kind of use it for a lot of their techniques. Um, but it's not a new technique by any means. In fact, we have been doing deep plane facelifts for the last 60 years, okay? So, what the deep plane refers to is we describe that muscular layer, the superficial muscularapeneurotic system. And that is the layer that is elevated, advanced, and tightened up in a deep plane facelift. Well, how is that different than any other facelift? A couple things. So the traditional described deep plane facelift goes into that layer or below that layer and doesn't uh create a separate layer of the skin on top of it. Okay. In fact, they they tighten that layer up as a composite flap. Okay, so the skin is attached to that muscle. It's a procedure that takes less time and you're repositioning that muscle. The other techniques that are out there are what are we called SMAS manipulation techniques, okay? And those can involve folding the SMAS on itself or excising a small piece of it and advancing it. And in general, those do not dissect really deep into the plane, the deep plane, but there is it's controversial as to whether or not they can be just as effective as deep lane facelifts.

SPEAKER_00 16:19

And so and let me just stop you for one second because what you gave me was an answer to what's a deep lane face and necklift. But I can't tell you the number of people I see marketing a deep lane necklift by itself. And when I ask you what's a deep lane necklift, I genuinely don't know what a deep plane necklift is. So, I mean, does anybody like really, you know, I'll see, I'll see surgeons online who are elevating optisma, which is the tail, the tail end of this muscle through the incision behind the ear, five centimeters, six centimeters, and then they're showing all these videos of their deep plane necklift. To me, that's just standard elevation of a smash flap. And so, you know, do you have to do gland work for it to be a deep plane necklift? Do you have to do a certain amount of platisma elevation, or is this a completely made-up term that is being used for marketing purposes?

SPEAKER_01 17:16

It's in the eye of the beholder. Yeah, in other words, it's a completely made-up term. Yeah, yeah. And so some people like our friend Francis Francisco from Spain, his deep plane is a true deep plane. He is going really deep and doing it safely. He's a master anatomist. Um, others, they're just kind of throwing some scissors in there, spreading some tissue, tightening it up. And that's my deep plane facelift or neck lift. And so it really is a marketing term, I think. You know, and in one of our podcasts coming up in the next few weeks is going to be all about the deep plane and kind of some of the celebrity controversy around this. So uh we'll temper a little bit of our discussion today in preference for that.

SPEAKER_00 18:00

Yeah. Yeah. And I and I the reason I was hammering that point so hard is I don't know about you, but so many patients that are coming in now will ask me, well, am I getting a deep plane facelift? They want to make sure they're getting an aggressive facelift. And to them, if it's not called a deep plane, it's not a good operation. Yeah. I even know of surgeons that are now doing the same facelifts that they've always done and now looking at them as deep planes. It's actually, you know, I don't, I don't, I don't understand why there's such a push for this, but it's happening everywhere.

SPEAKER_01 18:32

So, for example, you know, the the facelift that I learned in my fellowship was um, you know, taught to me by Foed Nahai and Mark Codner. They were students of of you know the Miami School. Um and you know, that was a high SMAS technique. Okay, you learn in Texas, you learn smash for LS and extended Smash, you know, extended SMAS, you know, it all had different terms, right? And so by definition, we're lifting up the platisma and the SMAS as one unit, we're cutting through ligaments, we're being careful not to damage nerves, and we're repositioning that to a higher place. That by definition, to me, is a deep plane facelift. Okay. It's not a composite facelift, it's both layers, but it's still actually even a lot more work than probably what is described as a deep plane facelift in today's day.

SPEAKER_00 19:22

So when people ask me, Am I getting a deep plane facelift? And I'll try to explain how an extended SMAS or a high SMAS is different. All they hear is that they're not getting a deep plane facelift.

SPEAKER_01 19:33

And then they are getting a deep plane facelift. In fact, I'm doing it one better than a deep plane facelift. I'm doing it in two layers, not one.

unknown 19:51

Exactly.

SPEAKER_00 19:52

So this is this is the challenge as a plastic surgeon sometimes, is giving the patients the results they need, but still sort of telling them what they need to hear. So um, you know, I think we spend a lot of time talking about alternatives to necklifts, and maybe hopefully what everybody conclude is there's very limited applications for for these alternatives. I think in men in particular, the ones that we see that are getting laxity, separation of the muscles, an isolated necklift can be a really good operation. What about in women? Do you think an isolated necklift is an operation that is as good as it is in a man? And if so, why not?

SPEAKER_01 20:28

Absolutely not. I think in general, um, women are much more attuned to facial aging than men are. And that and I think anatomically it's much different too. In general, if you look at the craniofacial dynamics of women versus men, men have have wider jaws, they have thicker bone on the lower portion of the mandible, and that lends itself to less jowling, I believe. In women, mandibles are thinner, they're they're less wide, um, there's less projection many times, and that unfortunately lends itself to a lot of jowling. And I think if you attempt to tighten up just the neck only, um, you're gonna leave some redundancy of skin in the jowls, which looks like an overdone look. Um, there is rarely a female patient that comes to me and says, I just want my neck addressed. I don't care about this area right here. So it's really, and that kind of begs the question well, um am I doing a facelift or a necklift? It's really all one. It is really the lower portion of the face and neck. It has to be done in continuity. Um, you know, common analogy I tell patients is let's say you were um, you know, buying a dress for an event and you go to Nordstrom Rack because you don't want to spend a ton of money. And then you basically get that dress and you try it on, and it is a little bit too big. If you take it to a cheap tailor, they'll say, okay, well, we'll just put a little stitch at the base at the at the waist. And then you try it on, and it looks weird because you need you need tightening of the bust, you need tightening of the A-line, it all needs to lay flatly. And that same concept goes in the face. You have to, if you don't pay attention to the dynamics of pulling, it's gonna come out looking unnatural.

SPEAKER_00 22:12

I could not agree more in women. But it's weird in men, again, it can be a different story. That's right. Yeah, and and uh, and you know, I think the way I explain it to men, uh, or you know, men are very worried about looking feminine after their facial aesthetic procedures. So when you do procedures that restore facial fat, it can be very feminizing. Right.

SPEAKER_01 22:32

Now, one other concept, too, in men that I want to talk about, which I think is a what I like to call a sleeper operation, men. It is a where you're going. I find it to be a fantastic operation that's easy to perform. The recovery is really easy. It's a it's a neck Z plasty. Okay. And this is an operation that I oftentimes offer patients, particularly if they're not concerned about a little tiny visible scar. So, what that is, is in a in in men, we oftentimes wear our hair shorter, right? So the traditional neck lift incision goes behind the ear. To me, that's going to be visible in somebody like you who wears their hair short or like me. Okay. A neck Z plasty will do the opposite. The it puts the scar down here underneath the mandible. And it's a series of little zigzags that kind of go back and forth that quite honestly blend right into the neckline. Men can wear collared shirts, men wear beards, and this can hide really well. And for somebody that has a loose neck, that doesn't want to take a lot of time for recovery, spend a ton of money, or have a visible scar or a less visible scar, then I think that is a beautiful operation. I love it.

SPEAKER_00 23:44

I've done a couple, and it is definitely a very powerful operation, for sure. Um, and the approximation and extent of muscle tightening you can get is intense. But do you honestly believe in a patient like me that's gonna be a less visible scar than one behind my ear? Absolutely. In me with type 5 Fitzpatrick skin and dark pigmentation, you think that's gonna be you'd feel more comfortable about that.

SPEAKER_01 24:10

What tell me about the scar that you're gonna have behind your ear? Two or three millimeters behind the hairline, it'll blend in. Turn your head for that in a second. Yeah, I mean you it'll blend in beautifully. Anybody at the airport would see that scar in you behind your ear. Yeah, not everybody will see the scar here.

SPEAKER_00 24:27

Um I respectfully disagree. I think most people would be on my side on that one. But we'll see. We'll see. It'll be interesting. Agree to disagree. Agree to disagree. And on that note, I think we're ending with the right amount of conflict. So um any last points you want to add?

SPEAKER_01 24:43

Uh I think, you know, last point is again for for the surgeons out there, I think, you know, anatomically, you've got to look at the layers and you gotta decide independently what technique for each layer.

SPEAKER_00 24:56

Agreed. Well, thank you again for watching our our episode of on necklifts, and we can't wait to see you for the next one.