I perform a deep-plane facelift, which involves releasing certain facial and neck ligaments to allow a proper, unrestrained elevation of the midface, jawline, and neck. However, in certain patients, about half or more of my cases, I also perform an additional deep neck lift. Unfortunately, the words “deep neck” and “deep plane” can be confusing and may make the reader think they are the same thing when they are not. The deep-plane component again refers to the way that I elevate the tissues during the facelift. The deep neck lift refers to reduction of a bulky neck, that is the physical reduction of a full neck in a specialized way which will be described more in-depth in this article, that may or may not accompany a deep-plane facelift.
So what is the deep neck? Let’s first explain what it is not. Many people, both young and old, complain of a “fat neck” and want liposuction, but this fails in almost every case. Fat that resides under the skin that is treatable with liposuction is not the culprit behind a full neck. In fact, when individuals have liposuction, they usually do not discern much improvement and that includes even non-surgical reductions of the subcutaneous fat like Kybella, Thermage, Ulthera, Face-tite, radiofrequency microneedle, etc. All of these techniques and more fail to deliver a discernible improvement in the neck. What is more they also may risk exposure of the underlying platysma muscle, which are the two vertical bands of muscles that show up with aging and that we refer to as the turkey-gobbler deformity. Accordingly, removing this precious fat under the skin may either yield very little outcome or worst predispose one toward premature aging over time by exposing these loose bands. This is particularly problematic in an individual over 40 years of age who already has sagging neck skin and exposed muscles only to be worsened by the liposuction or non-surgical liposuction equivalent. In the younger patient, liposuction may provide limited benefit but still the deep neck lift provides far better outcomes in neck contour than can be achieved with liposuction. For all of these reasons, liposuction is a failure in my opinion.
The deep neck then is the compartment of tissues that resides deep to the platysma muscle or inside it rather than outside it where the overlying subcutaneous fat is situated. The deep neck is composed of deep fat (subplatysmal fat), digastric muscles, and, most importantly, the submandibular glands. Reducing only the subplatysmal fat is also a mistake. Doing so can cause what is known as a “cobra deformity” where too much central fat is removed and the outer face simply looks bulky and sagging. The submandibular gland must be taken down in continuity with these other structures in order for a smooth neck to appear.
The natural question is whether it is safe to reduce the submandibular gland. The submandibular gland is one of many salivary glands, that is, a gland that produces saliva. Theoretically, one could have dry mouth after reducing it, but in studies in the ENT literature even removing the entire gland does not cause dry mouth, as we have about 1,000 minor salivary glands, two large parotid glands (that produces most of our saliva), two sublingual glands, and, of course, the remainder of the submandibular glands that are not removed, which is about 60% or so. The second negative comment that has been made about submandibular gland removal is the risk of taking too much out and having an overskeletonized and hollow neck, which I have simply never seen because the amount that I reduce is not arbitrary. I reduce the gland upwards to be flush with the jawline or mandibular border, which thereby not only improves the appearance of the neck but also the jawline. The third complaint others have made about the reduction of the gland is that it is unsafe since there are nerves around the gland, which is easy to avoid because I am actually in the capsule on the gland itself where there are no major nerves, so it is very safe for an experienced surgeon, and I perform this procedure almost weekly. The fourth complaint is that you risk bleeding and salivary leaks. For me, fortunately, I have never seen these issues when it relates to the submandibular gland because I use a specialized device known as a Covidien clamp that gives me an auditory beep when the gland is properly and completely sealed before I progress with cutting it. In short, I believe gland reduction is critical for a successful neck enhancement in certain individuals, and I will explain more in whom in the next paragraph. Digastric muscles are the final component and I will say that they do not perform a significant function in our neck, and I do not remove them but just thin out the muscle to flatten out the neck and I have not had any functional issues after doing so.
Who should have a deep neck lift procedure? To me there are two major categories of individuals who would benefit: the thin neck and the fat neck. I simply pull up on the neck and look from the side view. If the neck looks clean no matter how much sagging, then that person does not need the procedure done, so age is not a determining factor. I can have a 70 year old who does not need it and a 30 year old who does. However, even in the thin neck, a deep neck lift can be quite beneficial because I sometimes see a residual golf ball, which is the gland being visible after a facelift. If you have had a facelift or seen a friend of yours following his or her facelift and noticed that there is a small round fullness on either side of the neck, that bulge is the gland that should have been reduced and was not. The most obvious indication for gland reduction is the fat neck or full neck that simply needs to reduce this deep neck component to have an excellent result. For younger patients under 40 years of age, the deep neck lift may be all that is needed since there is no sagging jowls or face but just a full neck. In younger patients with good skin elasticity and no sagging, I perform an isolated deep neck lift focused on just reducing the fullness of the neck without the deep-plane facelift component of elevating the sides of the face. Accordingly, this procedure can be done as a standalone in younger patients born with a full neck even as young as the teenage years and should be the ideal method over other less successful surgeries like liposuction, etc.
You may ask yourself why haven’t you heard of this procedure before? Simply put, about 99% of facelift surgeons are uncomfortable to do the procedure because it requires considerable experience and skill. Most surgeons are untrained to tackle this problem. I am very passionate about the deep neck lift and really believe there is no easy workaround to improve a bulky neck or a thin neck showing an exposed gland other than physically reducing the bulky element of it. Some have argued that suspending the gland is an acceptable alternative but I do not believe that this method adequately provides uniform and consistent results that are sustainable long term. The reason that the gland becomes visible as we age has been shown in MRI studies not to be related to an increase in size but due to gravitational descent of the gland. Sorry for this long blog post but there was not short way to explain this important topic. I encourage you to watch part 3 of my facelift series to revisit some of these ideas presented in this blog post.
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