Help for that sagging neck

Nora Ephron’s blockbuster 2006 book, I Feel Bad About My Neck, touched a nerve for a lot of people. The truth is that as we age, the skin on our neck loses elasticity and can begin to sag.

“As we get older our tissues become thinner and that’s every layer of our tissues, so our skin gets thinner, the fat gets thinner, the muscle gets thinner and actually the bone also gets thinner,” said plastic surgeon Julian D’Achille, MD, MPH at Cape Cod Healthcare Plastic Surgery in Mashpee. “Everything starts to thin out as we get older and it starts to sag because gravity does take its toll.”

People who have more fat in their faces tend to look younger because the tissue is thicker, Dr. D’Achille said. Conversely, people who are overweight who go on to lose a lot of weight either through diet, medication or bariatric surgery find that their former weight stretched out their skin and now they have an excess of skin that sags in unattractive ways.

Surgical and Non-Surgical Remedies

When patients come to Dr. D’Achille to ask about getting a neck lift, the first two things he asks them is why now and what is it about your neck that you don’t like?

“There are certain things we can do that may address that area in particular that may not even be surgical,” he said. “This is one of the areas that treatment is very different depending on what the problem is.”

For some people, the problem is excess skin. Others have excess subcutaneous fat, for some people it’s both. Where the problem is located also matters. For some people, the distribution of tissue is through their entire neck. For others, it is located in the center of the neck.

“The treatment is going to vary depending on if it is a skin problem or a tissue problem and then also where is the location of that problem,” he said.

In younger patients, if the skin just needs to be a little bit tighter, laser treatments or chemical peels can help. For patients with too much fat primarily in the center of their neck, an injection of Kybella, an enzyme that breaks down fat, can help.

“Another nonsurgical option primarily to treat fat, not skin, is cool sculpting,” Dr. D’Achille said. “I always get the question, ‘Does it really work?’ Yes, it does. It literally freezes the fat and then your body breaks the fat cells down.”

One surgical option for fat is liposuction. There is laser liposuction, ultrasound liposuction or traditional liposuction, which is what Dr. D’Achille does.

“It’s done under anesthesia and that really can be done to treat fat in any location of the neck,” he said. “It works really well on the central part of the neck but it can be done elsewhere on the neck too.”

For skin, the only real surgical option is a neck lift, which is done by making incisions that go around the ear into the hairline and then dissecting down through the skin so that he can pull the excess skin out and remove it. It can be done in conjunction with liposuction, if there is too much skin and too much tissue. It can also be done alone or in combination with a facelift.

Look at the Whole Face

When Dr. D’Achille meets with a patient who asks about neck surgery, he also looks at the patient’s entire face and not just their neck. If someone comes in with really droopy skin on their neck and on their face, with prominent jowling, a neck lift alone won’t address the jowling, he said.

“If they have both problems, I’m usually going to tell them to do (a neck lift and a jowl lift) because that’s going to be the better result,” he said.

Another aspect of aging, when it comes to our necks, is the platysma, which is the muscle that is responsible for clenching your jaw and opening your mouth. As people get older, and it’s more prominent in women, the platysma thins, the muscles split at the midline and separate into platysma bands on either side of the neck. Those can be treated with Botox, Dr. D’Achille said.

“However, if you are having a neck lift and you have platysma bands, then we suture the muscles back to the midline,” he said.

Women aren’t the only ones who seek out neck lifts, but it is less common in men because men tend to retain a fullness in their neck and their tissue is a little thicker. In 2020, there were 160,00 neck lifts in the United States, Dr. D’Achille said. Of those 160,000, 138,000 were women and 22,000 were men. He points out that 2020 was an unusually low year because people didn’t seek as many cosmetic treatments during the pandemic. For comparison, the number of neck lifts in 2019 was 181,000.

The number of facelifts for both men and women in 2020 was 234,000.

“Bear in mind these numbers don’t include things like Botox and fillers, which are far and away more common than doing a neck lift,” he said.

Surgery Not for Everyone

Before surgery, each patient is screened very carefully to make sure they are healthy enough for the surgery. The number one complication of the surgery is bleeding, which can lead to necrosis of the skin, so people who take blood thinners would not qualify for it. Neither would people with high or uncontrolled blood pressure. Smokers are also excluded.

“The other thing we talk about is a really thorough review of medications, supplements in particular, because there are some supplements that are known to increase your bleeding risk,” Dr. D’Achille said.

One of the most common questions patients ask is, “How long is this going to last?” The answer depends on what procedure you have done. Botox lasts about three months. Fillers last anywhere between nine months and 18 months, depending on the type of filler used. Laser treatments last three to five years and face or neck lifts last roughly ten years.

“Nothing that we do is permanent,” Dr. D’Achille said. “Even surgery is not permanent. It can be repeated but you don’t want to be doing this every ten to 15 years. You want to do it when it makes the most sense.”