Most people can describe what they view as an aesthetically ‘ideal’ neck. Features associated with a ‘youthful’ neck typically include
1) A smooth and defined jawline
2) a smooth neck contour
3) definition between the jaw and neck
4) No Fullness under the Chin.

The Aging Neck

As we age, several key changes occur. These changes are due to genetic and environmental factors, mainly sun exposure.

As people age there are some typical changes we see in the neck:

1) the skin under the neck begins to loosen,

2) the fatty tissue under the chin can become more pronounced

3) the muscle bands under the skin can be seen.

4) Additionally, the deeper structures within the neck, such as the salivary glands, can start to drop and become more visible.

Layers of the Neck

Many patients come to our clinic concerned about a " double chin, " a “turkey neck, " or loose skin under the chin.

Understanding the anatomy of the area under the chin and neck is essential to understanding how we treat it.

There are, in essence, five layers to be aware of:

1) Layer 1 - The Skin

Neck Fat and Submental Fullness — Supra-platysmal Fat

2) Layer 2 - Supra-Platysmal Fat: the fat between your skin and the flat muscle in your neck, the Platysma Muscle. There is typically no more than 10-20ml of fat in this area.

3) Layer 3 - The Platysma Muscle: a large, very thin muscle that covers most of your neck.

4) Layer 4 - Sub-Platysmal Fat: The fat under the platysma muscle that helps protect deeper neck structures

5) Layer 5 – Deep Neck Tissue: Digastric Muscles, Hypid Bone and Salivary Glands. Whether it be surgery or liposuction, we rarely, if ever, treat the tissue below the platysma. Therefore, all treatments target layers 1 – 3. Different treatments target different layers, which we will discuss later.

Evaluation and Assessment of the Neck

When assessing a patient with neck concerns, we want to understand three important features: the skin quality, the amount of fatty tissue, and the appearance of the platysma muscle. Careful assessment of these features is required to determine the most appropriate treatment.

Evaluation of the skin (Layer 1). Patient age, sun exposure, and smoking history are the most critical factors contributing to skin aging. I can’t stress enough how important sunscreen and sun protection are in the neck's aging.

The ideal situation is that the skin is tight and healthy. The opposite is loose skin or thin and wrinkled skin.

Evaluation of the Submental Fat (Layer 2). Understanding how much fatty tissue is under the chin can help determine the most effective treatment. You can pinch the fat with your fingers, which helps show you how much is present and how much can be removed.

Evaluation of the Platysma Muscle (Layer 3). In younger patients, the platysma muscle is flat and not visible on examination. As we age, we can see the ‘bands’ that run down the neck under the chin. This is the edge of the platysma muscle. Knowing how loose and visible this muscle is is essential before recommending a specific treatment.

Evaluation of the Deep Neck Fat (Layer 4)—This deep fat is more challenging to assess. If a patient has significant deep neck fat, it is typically not removed and needs to be part of the patient's expectations.

Evaluation of the Deep Neck Structures (Layer 5)—An assessment of the salivary glands is important, as people with prominent glands may notice them become more visible after surgery. Understanding the deep neck structures can help inform you about the potential results you can get with different procedures and help guide your expectations.

Treatment Options and Selection

One of the most difficult decisions in this process is determining which treatment will provide the best results at the lowest risk. When making recommendations, I try to balance the risk versus the benefit of a procedure. Some patients are willing to take on more potential risks for better results. The critical question I ask patients is, “Is a 5% increase in the potential benefits enough if there is a 20% increase in risk?” “How much of a benefit do you expect to move into higher risk procedures?”

All procedures, whether surgical or medication-based, carry some risk. Understanding this balance is key to making the best choice for you.

Surgeons have several methods for improving a patient's neck. One can consider the different layers noted above when considering the best or most appropriate options. Each treatment targets different layers of the neck.

Skin Care—Layer 1 Only:
Skin creams and products should be used to target the first layer. This will not affect any other layers. This is an excellent option for all patients, as improving skin quality will always offer some improvements with minimal risk. Numerous treatments, such as hyaluronic acid products, serums, and retinol-based products, can help.

Of course, sunscreen is the best method to prevent further aging.

Skin Tightening Lasers and Other Technology—Layer 1 Only
Many lasers and ultrasound-based treatments can help tighten the skin. These treatments can be very effective in the right patient with little to no downtime. The key to understanding if these are right for you is understanding their limitations and having appropriate expectations. They are a wonderful option for people who can not have surgery.

The best patients for this treatment are (1) Young patients with minor neck aging, (2) Patients who want an improvement but are not willing to undergo surgery, and (3) Patients who can not have surgery due to medical reasons.

Dermal Fillers – Layer 1 (and can affect layers 2, 4, 5)

Fillers can improve the jawline and, in some situations, tighten the skin of the neck. They are generally safe and can often have beautiful results; however, they are usually not long-lasting (1-2 years). Fillers are best for people who want a quick result with limited downtime and low risk. However, the patient must understand that the results may not be as dramatic as those of other treatments.

Two techniques can be performed using fillers:

Technique one is the traditional use of fillers. We can inject filler to sculp and change the shape and volume of different areas. This can potentially alter all layers of the neck, but primarily add volume and bulk.

Technique number two involves diluting filler and injecting it under the skin. This results in an inflammatory reaction of the skin which can result in skin tightening. This is a very effective treatment when a person wants low-risk improvement.

Appropriate patients for dermal fillers:

1) Mild to moderate aging of the neck

2) Healthy Skin

3) Want a quick result with little or no downtime

4) Understand the limitations and have appropriate expectations that the results will be subtle

5) Understand that the results are temporary

Chin Implants – Layers 1,5. Chin implants in the right patient can result in dramatic results in the neck. They can increase skin tension and reduce loose skin under the neck. However, they carry higher risks, as some people do not like the feeling of the implant in the body after treatment. They are also surgical procedures and carry typical surgical risks

Appropriate patients for Chin Implants:

1) Have a small chin

2) Loose skin under the chin

3) Not a lot of fat under the chin

4) willing to accept the risks that go into a chin implant and surgery

Liposuction—Layers 1 and 2

Liposuction under the chin and along the jawline can dramatically improve the neck. This treatment can reduce the fatty tissue and tighten the skin as it heals. Similar to the treatments above, there is risk involved in this surgical treatment. However, the risk is much lower than a standard neck and facelift. There are only three tiny, almost invisible scars, and healing is much faster than a formal neck lift.

Appropriate patients for Submental Liposuction

1) Have moderate to excellent skin quality and elasticity

2) Have mild or no platysmal banding

3) Mild to moderate loose skin under the neck

4) If they do have platysmal banding, understand that this will not change after the liposuction

5) Understand and accept the risks associated with liposuction

Surgical Neck Lifting and Cervicoplasty – Layers 1, 2, 3: This is the most invasive treatment option. However, it can potentially have the most dramatic results. The downside is that a neck lift carries the highest risk. The treatment has the longest healing time and the most downtime. In the right patient, a neck lift has dramatic and long-lasting results.

Appropriate patients for Neck Lifting:

1) Have loose skin under their chin

2) Good to Poor elasticity of the skin

3) Obvious platysmal banding

4) Healthy Patients

5) Accept the risk associated with the surgery

6) Willing to accept the extended downtime and scars

Before and After Pictures of Submental Liposuction performed by Dr Bonaparte

Summary

The Challenge for the patient and the surgeon is choosing which procedure is best for them. All the treatments above provide some benefit at minimal cost.

Book your appointment with Dr Bonaparte now to see the best treatment for you.

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