FACE & NECK Note: All procedures shown were performed by Dr. Churukian, and no photos were altered to enhance the results. SURFACE ANATOMY OF THE NECK The first layer of muscle under the neck skin is called the platysma. It is easiest to see here running from the collarbones to the jawline in a thin neck. The muscle edges have visibly separated in the middle, giving a “turkey gobbler” effect. In the diagram on the left, the edges of the loose platysma muscle have been brought back together with strong dissolving sutures. Beginning more than thirty years ago, we added a permanent zig-zagging suture (shown on the right). This suture goes up and down the muscle to help strengthen and stabilize the muscle. This process results in a smoother, tighter neck (and better longevity). THE NECK This is an obvious example of a loose platysma neck muscle that has separated in the middle (before). Sun damage to the skin is also visible. There is little excess fat in her neck. After the tightening procedure, the muscle is smoother and tighter, giving a more youthful and still natural appearance. Here you can see the result in three-quarter profile after the neck muscle has been both tightened in the middle (as shown in the previous photos) and pulled up behind the ears. The jawline was also tightened and the skin resurfaced to reverse sun damage. Here you’ll see the first patient who - over 30 years ago! - motivated me to use a permanent zig-zag suture to help keep the neck muscle tight. She also had a weak chin. You can see her one year later, after the platysma muscle was tightened and a chin implant, with a good result. But how long would it last? We formed a friendship, and over the years, we were both pleased that she aged “gracefully.” I have included that permanent stitch every time we tighten the platysma muscle in the middle since her surgery. Of course, everyone is unique in how they heal, and in how long the results will last. RESULTS AT DIFFERENT AGES Is there an ideal age for surgery? The short answer is no. Each of us is unique and physically different. Whatever motivates us to have an elective procedure will differ, and may occur at various ages. The examples below showcase some of the results patients have had at different stages of life. RESULTS: 40’S Sometimes, a well-defined neckline is just not a part of the anatomy, regardless of age, weight, or fitness. Pictured here is one of my neighbors, only in her forties, who always had a loose platysma and excess fat. Trimming her fat and tightening her platysma were key to an improved neckline (and good neighbor relations). RESULTS: 50’S Typically, we notice changes in the jawline and neck by our fifties (as here). This age has traditionally been considered good timing for a face and neck lift, because the skin and muscles are strong and healthy. This can result in a longer-lasting effect, without an overly dramatic difference. RESULTS: 60’S This patient was a professional, re-entering the workforce in her mid-sixties after retirement, and wished to look younger. She felt that her more youthful appearance after surgery was a factor in being rehired, and she continued to work into her late seventies. RESULTS: 70’S Here we see someone in her mid-seventies, who fell on an uneven sidewalk, breaking her nose. I suggested that in addition to straightening her nose, we tighten the neck at the same time, and transfer some of her body fat to areas of her face. At this age, the results can be more pronounced. We were both pleased that the neck was tightened, and I felt that it made a bigger overall difference than the nose. HOW LONG DOES IT TAKE TO HEAL? First of all, healing is gradual. At one month, there is still visible swelling and bruising. It takes one year or more for the final improvement in the neck and jawline. HOW LONG DOES IT LAST? We used to say this would last 5-10 years, although it is probably longer now. In this example her salivary gland (just under her jowl) is hidden before surgery. After tightening the platysma and trimming the excess fat the salivary gland became more visible. Does she still look better? Yes, she does. She will always look better than if she had never had a face and neck lift. What about the gland? It can be partially removed but there are significant risks. THE JAWLINE The platysma muscle in the neck continues upward into the cheek as a layer of collagen under the skin abbreviated as the SMAS. A Swedish plastic surgeon in the 1970s carefully tried tightening this SMAS layer in the cheek during his facelifts to improve results. Prior to this only the skin was tightened for a facelift. The “skin lift” alone can visibly distort facial features and the skin will gradually stretch back after being pulled. Virtually all facelifts now use the stronger SMAS to tighten the lower face and jawline for a more pleasing, natural, and longer lasting result. The SMAS as a continuation of the platysma muscle can be lifted and tightened in the cheek area. This draws the jawline up with it, and helps to smooth the jowl as well. Although there are many variations in facelift technique the SMAS is tightened in nearly all cases. We start to notice a jowl as the soft tissues of the face relax, and gravity has its way with us. Here, the platysma is tightened in the neck, and then the SMAS is tightened in the cheek. This lifts and smooths the neck and lower face. Tightening the SMAS in the cheek tends to streamline the lower face from the front, creating the characteristics of a more youthful face. (That bright lipstick helps, too!) NECK & WEAK CHIN The chin normally tends to recede gradually as we age. As a result, a “weak” chin can emphasize the aging appearance of the neck. Here, a chin implant has improved the balance in the overall profile. In the same patient, tightening the platysma muscle in the middle and tightening both the skin and muscle from behind the ears can help smooth the neck skin. The chin implant gives a subtle strengthening from the front view. NECK AND NOSE Do the ears and nose really “grow” as we get older? This patient felt that her nose was gradually drooping, so we lifted it back up during her face and neck surgery. Now the face, neck, and nose all look more youthful together. NECK, JAWLINE, & FAT GRAFT Commonly as we age, we lose the fat or volume in our faces. Replacing some of that fat during surgery yields a more natural and pleasing result. Here we see an early example; some of that fat will be permanent. We wait six months to a year before deciding if we want to add more fat. OFFICE TUCKS (1) OFFICE NECK TUCKS What if you don’t need much? Can anything be done as an office visit with pills and local anaesthesia? Yes: let’s explore three of the most common tucks we often do as office visits. Here is a patient with loose neck skin, both before and six months after an office neck tuck. From a frontal view of this patient we see that the neck tuck is designed to help smooth the neck skin. Either the skin or the platysma muscle (or both) are tightened from behind the ears. This patient also had fat grafting for her face. The office neck tuck is especially well suited to someone who has had prior face and neck surgery. There tends to be less swelling and much less bruising. Here (24 hours later) the sutures can be seen at the earlobe. They then go behind the ear and into the hair. She goes home with a driver after surgery and returns sometime during the following week to have the sutures removed. After previous face and neck surgery, a layer of collagen forms just under the skin. Fortunately it tends to become especially thick and strong behind the ears. Tightening this thick layer behind the ears effectively pulls up the neck skin and platysma muscle with it. Here, we took advantage of this strong collagen layer to tighten and improve the appearance of her neck. (2) OFFICE JAWLINE TUCKS Just as the neck can be tightened under local anesthesia and pills during an office visit, the same can be done for a subtle improvement in the jawline. The SMAS is here tightened in the cheek, helping to smooth a small jowl. She also had a laser treatment for her skin. This tightening of the jawline in the office is often accompanied by using fat to soften and smooth areas of volume loss in the face. Here a laser was also used to help with lines and wrinkles in the cheeks at the same time. (3) OFFICE JOWL TUCKS Even in the younger age group, jowls have a way of sneaking up on us. The simplest fix is microliposuction with local anaesthesia, usually performed while the patient is just sitting in a chair. This patient also had a little fat removed from her neck. Following a facelift (performed elsewhere) it appeared that fat had been sucked out of her face but a jowl had been left behind. Neither of us were interested in another facelift, and it would not have helped in any event. Instead, we put some of her fat back into her face and jawline and removed both fat and a strip of skin from under her jowl. This required several office visits, but gave a smoother and more natural looking result without the need for another facelift. NECK AND SKIN The baby boomers are a generation that grew up without the protection of sunblocks. A laser to resurface sun damaged skin can be used to enhance and complete the results of a face and neck lift. A result of the original CO2 lasers (not fractionated) as seen here in the same patient was smooth skin, but sometimes lighter in color. With the current fractionated lasers, the skin may not be quite as smooth, but the color changes are minimal. NECK AND FULL FACE We would like our whole face to look more “rested” after surgery and that may include additional procedures. Lifting the forehead and brows also tends to brighten the eyes and give a more youthful appearance. The brow lift is done endoscopically through short incisions in the hair under general anesthesia. Fortunately, it can be done without that “deer in the headlights” look. FACE & NECK INCISIONS What about the incisions? Are they in front of the ear or behind? In order to tighten the jawline and neck, and to remove extra skin, the incision follows the edge of the ear and then goes behind and into the hair. In a man, the beard moves closer to the ear. If these incisions heal normally, they are difficult to spot. This is especially important for men or anyone with short hair. With normal healing, the incision usually becomes inconspicuous within several months. Here, the patient is five weeks after surgery and the incision is pink, making it visible at the earlobe. It is most important not to distort the normal appearance of the ear and earlobe. We want it to remain looking normal and natural. The skin can take up to a year to heal fully in people with medium to dark complexions. Here, the incision is still somewhat pink at six months, and just barely visible at the earlobe after one year. In very fair skin, the incision gradually lightens. Here, after nearly six months, it is just lighter than her skin in some areas, but difficult to see without getting very up close and personal. WHAT ABOUT MEN? Very often men are interested in improving their necklines. Here we see a small amount of sagging skin and muscle in the neck. Can the neck be tightened without a facelift? We used to say no, but the answer is actually yes. Most men really just want their necks tightened without visibly altering their faces. A major concern, especially of men, is how long before going back out in public? We suggest letting the hair grow a bit longer and not shaving for three days before surgery. Usually by ten days to two weeks the swelling and bruising are not apparent, and are even less so if the beard grows. Here we see in the neck a combination of sagging skin, excess fat, and loose platysma muscle. The chin is also receding. From a short incision just under the chin, fat was removed, the muscle was tightened, and a chin implant was placed. From the area around and behind the ears, the excess skin was removed. At one month, he looks like he has lost weight (and to be fair, he did lose a few pounds). The neck was tightened enough that we can now see his Adam’s apple. When there is a large excess of neck skin, we anticipate a future office neck tuck. This is because there is a limit to how much tighteneing the skin and muscle will tolerate. Also, there is a natural process of relaxation with healing. This patient continued to lose weight and kept it off, which can also loosen the skin. We never did get around to an office tuck, and his skin held up well enough that it wasn’t necessary. We did do microliposuction of his jowls at an office visit a few years after surgery. FACE, NECK, AND FAT When is a facelift not a facelift? What can be done without making any incisions? Occasionally we will start with a fat transfer for a thin face before considering surgery. Here, we added fat in two sessions and avoided surgery altogether. This patient was also considering a facelift, but we decided to try a fat graft to her jawline first. She previously had filler for her smile lines by a dermatologist. Fat grafts are most effective for broader facial contouring. After the fat graft and filler, we were both satisfied with the results and postponed any surgical facelift. 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