Direct Neck Lift For Men: Jeffrey T. Gu,, Tom D. Wang,, Myriam Loyo

Di rec t Neck Lift for M en
Jeffrey T. Gu, MD, MS, Tom D. Wang, MD, Myriam Loyo, MD, MCR*
KEYWORDS
Direct neck lift Platysmaplasty Cervicoplasty Rhytidectomy
KEY POINTS
Direct neck lift approaches, with limited dissection and fast recovery, may offer significant benefit
for patients who may not desire full rhytidectomy.
Disadvantages of the direct neck lift for the aging neck include the visibility of the incisions and
scars as well as the limited area of the treatment in the neck.
Direct neck lift surgical techniques address excessive skin and provide access to underlying sub-
mental and submandibular areas giving exposure to the underlying fat, platysma and digastric mus-
cle, and hyoid bone.
Patient selection, preoperative screening, and counseling are important to address in order to
obtain optimal results during direct neck lift.
The Grecian urn design with a Z-plasty at the level of the hyoid and platysmal plication is our
preferred approach. An overview of many of the most commonly used direct cervicoplasty ap-
proaches is given.
INTRODUCTION recovery. The disadvantages of the direct

approach are inherent to the relatively limited
The neck is a critical component of facial aes- area being addressed and visibility of the incision
thetics, as it plays a vital role in defining the jawline and resulting scar.
and overall facial balance. Submental fullness and Direct excision of submental fullness and redun-
laxity of the cervical skin are a common complaint dant skin offers an excellent alternative to rhyti-
of patients seeking aesthetic consultation. Many dectomy in many clinical situations, and many
male patients present for evaluation of a “turkey surgical approaches and techniques have been
gobbler” or “turkey waddle” deformity1 and described. In this chapter, the authors provide an
complain of redundant tissue in the submental overview of direct submentoplasty techniques as
area that rubs against the shirt collar or is pinched well as clinical pearls to consider in the preopera-
when wearing a necktie. tive, intraoperative, and postoperative periods. All
Patients often present with concerns that would of the approaches described allow for excellent
benefit from rhytidectomy but may not desire to access to the structures deep to the skin and
undergo a full rhytidectomy. Many of these pa- may incorporate additional treatment options as
tients may be reasonably well served by a direct indicated to address the underlying musculature,
neck lift. There are a multitude of limited direct fat, and skeleton. Given the degree of variation of
excisional techniques to consider if submental submental fullness with which patients present, it
fullness is the patient’s primary concern. The ad- is beneficial to be familiar with several different
vantages of a direct neck lift compared with rhyti- techniques to address the submental and sub-
dectomy include shorter operative time and faster mandibular areas.
facialplastic.theclinics.com
Department of Otolaryngology–Head and Neck Surgery, Oregon Health & Science University, Portland, OR
97239, USA
* Corresponding author. Department of Otolaryngology–Head & Neck Surgery, Division of Facial Plastic and
Reconstructive Surgery, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Port-
land, OR 97239.
E-mail address: loyo@ohsu.edu
Facial Plast Surg Clin N Am 32 (2024) 353–360

https://doi.org/10.1016/j.fsc.2024.02.004
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354 Gu et al
DISCUSSION preoperatively. Although it is possible to perform re-

Preoperative Considerations sections of the digastric musculature and subman-
dibular glands, sufficient improvement may often be
Appropriate patient selection and preoperative
achieved with skin removal alone.7 Additional con-
planning are imperative for successful results.
siderations including placement of a chin implant
Skin elasticity, submental fat accumulation, and
may also be performed through the same incisions.
platysmal strength vary by individual and age
Alternatively, a circum-occipital extended neck lift
and are responsible for the shape of the neck.
has been proposed, where incisions are placed
The ideal cervicomental angle ranges between
posteriorly and excess skin is advanced posteriorly
90 and 105 , with the vertex at the hyoid bone
along the hairline. However, this technique is best
and limbs extending tangentially through the gna-
for patients without significant submental liposis.8
thion superiorly and sternal notch inferiorly.2 The
Furthermore, although there are several techniques
effect of aging on the submental structures leads
to perform neck lifting without skin excision, such
to changes of the skin, fat, and muscle. The skin
techniques require patients with minimal skin laxity
relaxes due to degeneration of the collagen and
and are beyond the scope of this article.9–11
elastic fibers and begins to hang beneath the
General and systemic considerations are impor-
mandible. With aging, some patients may develop
tant to consider and manage appropriately. Ideal
an increase of fat deposition in the submental and
candidates have no systemic or complicating fac-
submandibular areas, leading to a loss of the
tors related to their healing ability or safety during
youthful neck contour. Furthermore, with aging,
elective surgical procedures and have established
the platysma becomes flaccid, fibrous, and con-
realistic expectations and goals. The direct neck
tracted, leading to varying amounts of platysmal
lift approach is preferred by patients for whom the
banding.3,4
neck is the sole source of concern or by patients
Many patients present for consultation desiring
who are time constrained, risk adverse, or medi-
something less than a face lift to improve their
cally unfit for a larger procedure.4 Anticoagulant
neck. Patients must be counseled of the fact that
medications including aspirin, nonsteroidal antiin-
all direct excisional techniques will involve a scar
flammatory drugs, and blood thinning supplements
of the anterior cervical skin that may be visible,
should be stopped. Tobacco or nicotine use should
especially early in the healing process. The poten-
be discontinued and avoided at least 2 weeks
tial risk for hypertrophic scarring and need for
before and after to surgery to reduce the risk of
additional procedures must also be discussed. In
skin necrosis, but the patient should be aware
addition, the patients must understand the limita-
that they are still at a higher risk of skin compro-
tions to a direct neck lift approach, namely that
mise. Tobacco consents describing that risk would
the procedure is designed to address the neck
be advisable for legal protection and to document
and would not address facial rhytids.5
informed consent. Further, it is important to
The most successful results are seen in healthy
counsel the patient that there would be a risk of
patients without systemic disease who have these
hair loss along the incision length due to trauma
soft tissue and structural characteristics—ptotic
to the adjacent hair follicles despite utmost care
and loose skin and musculature of the neck
not to injure them. Direct neck lift may be performed
extending no lower than the thyroid cartilage, min-
on an outpatient basis and can often be performed
imal jowl formation, with favorable chin projection,
with local anesthesia alone or in combination with
a higher hyoid anatomic position—and are mini-
intravenous sedation. We recommend placement
mally obese.5 The obese patient with heavy de-
of preoperative markings with the patient in the up-
posits of adipose fat along the jawline near the
right position before infiltration of local anesthesia.
submental cervical area is a favorable candidate.
The displeasing aesthetics are more difficult to
Physical examination should evaluate neck skin
ascertain in the supine patient.
quality and elasticity, platysmal banding and laxity,
amount and location of submental fat, position of
the hyoid-thyroid cartilage complex, submandibu- Direct Submentoplasty Techniques
lar gland position, and mandibular/mental projec-
In the following section, the authors review existing
tion. Patients with more extensive laxity, adiposity,
surgical techniques for limited direct submento-
and platysmal banding may still be treated with
plasty. Different incisions will be reviewed. All of
direct neck lift with significant improvement but
the approaches discussed allow excellent access
may require incisions to be extended to a lower,
to the structures deep to the skin and accordingly
more visible portion of the neck.6 Relative anatomic
may incorporate various treatment options for the
issues including submandibular gland ptosis may
underlying platysma and digastric musculature,
affect results and should also be considered
fat, and identification of the hyoid bone.
Direct Neck Lift 355
Elliptical Excision lateral flaps are pulled only in a horizontal vector,

the Lazy-H–shaped incision removes excess skin
The earliest descriptions of submentoplasty with
in the horizontal direction and does not affect verti-
elliptical excision were reported by Maliniak in
cal skin length.
1932 and Johnson in 1955.12 In their report, an el-
lipse of skin at or below the level of the hyoid is
T-Z Plasty
marked and excised in a transverse fashion.
They advocate that direct elliptical excision can Originally described by Cronin and Biggs in
be combined with rhytidectomy as well as direct 1971, the T-Z plasty is a similar method of skin
lipectomy and platysmal imbrication.1 The primary excision to the Lazy H–shaped incision except
disadvantage of direct elliptical excision is the that the horizontal components are elliptical
possibility of contraction bands that may form instead of linear (Fig. 2).13 The incisions are
from leaving excess skin in the lateral direction or designed with a superior ellipse at the level of
a deficiency of skin in the vertical direction.13 the submental crease, followed by a vertical
limb at the midline. Flaps are undermined lateral
Lazy-H–Shaped Incision to the vertical limb, and excess skin is resected.
The platysma is plicated down to the level of the
Morel-Fatio described the Lazy-H approach in
hyoid. Submental fat between the anterior bellies
1964 with an incision design resembling an H lying
of the digastric muscles may be addressed
on its side (Fig. 1).12 Incisions are marked with two through this approach. Z-plasties are placed
horizontal and one vertical incisions. The horizontal
within the vertical portion of the lateral skin flaps
incisions are positioned with the superior incision in
with limbs no longer than 2 cm each. There is
the submental crease or just inferior to it and the
often a resulting dog-ear inferiorly at the level
inferior incision sitting lower in the neck depending
of the hyoid, which may be excised as a smaller
on the deformity. The vertical limb connects the
horizontally oriented ellipse. The closure is rec-
superior and inferior horizontal incisions in the
ommended to be “quite snug,” otherwise insuffi-
midline. Wide undermining is performed laterally
cient tissue has been excised.
to the vertical limb, and the lateral flaps are elevated
and advanced toward the midline. Overlapping
W-Plasty
skin may be excised as the vertical portion is reap-
proximated and closed directly. Alternatively, a Ehlert and colleagues sought to further refine sub-
Z-plasty may be used to break up the vertical mental skin-excision techniques and proposed the
limb. Deeper structures of the submentum may submental W-plasty in 1990.14 The incision is
also be addressed via this approach. Because the planned by marking the lateral extent of excess
Fig. 1. Lazy-H–shaped incision. (A) An incision is made by marking one vertical and two horizontal incisions. The
center segment of skin is excised and discarded. (B) The lateral flaps are undermined and advanced to the
midline, and the incision is closed with a Z-plasty. The appearance of the incisions is that of an H lying on its side.
356 Gu et al
Fig. 2. T-Z plasty. (A) An incision is created by first excising an ellipse of skin in the submental crease. A vertical
incision is then made inferior to the ellipse, and the flaps are undermined. (B) The excess lateral skin is excised and
discarded. (C) Excess fat and platysma also are often treated at this step. (D) The vertical limb is closed with a
Z-plasty. Dog ears at the inferior extent of the incision may be corrected with another elliptical excision.
skin. Horizontal incisions are marked at the level of W-plasty is then closed in layers. Occasionally,
the submental and the suprahyoid crease. At the dog ears may be present at the superior- and
lateral extent of excess skin, a vertically oriented inferior-most aspects of the repair and may be
W-plasty is designed with multiple arms excised by removing triangular portions of skin at
measuring no longer than 1 cm each. The flaps the apex of the dog ear. The W-plasty disrupts
are undermined laterally, and any excess submen- the vertical portion of the scar and leads to a
tal fat is removed. A vertical strip of excess skin is much less apparent midline scar, which is hidden
excised as marked for W-plasty (Fig. 3). The within the shadow of the submentum.
Fig. 3. W-plasty. (A) Horizontal markings are made at the level of the submental crease and the suprahyoid
crease. The horizontal incisions are made, and a vertically oriented W-plasty is designed. The central strip of
excess skin is removed, preserving the W-plasty configuration. (B) The W-plasty is closed.
Vertically Oriented Elliptical Excision with a Bilateral Hemi-Ellipse

T-Closure
Hamilton described a limited submental lipectomy
Miller and Orringer described a vertically oriented with skin excision in 1993 by excising two hemi-
excision of an ellipse of skin with T-closure in ellipses.16 A midline incision is marked, followed
1996.15 An ellipse is marked at the level of the by arcs diagonally oriented from each other in the
submental crease superiorly. Inferiorly, the inci- configuration of a naval flag. The midline incision
sion may cross below the level of the hyoid is made, and an arc of skin and subcutaneous fat
depending on the severity of the deformity but is removed from one side of the superior portion
usually lies above the notch of the thyroid carti- of the ellipse, followed by an arc at the contralateral
lage. The elliptical incision is carried down to the inferior portion of the ellipse (Fig. 5). The remaining
level of the platysma, removing excess subcu- flaps of the ellipse are widely undermined in a
taneous fat. Undermining is performed at the supraplatysmal plane. Platysmal plication and any
superior aspect of the ellipse and laterally for appropriate fat removal are performed. The flaps
about 6 cm in a supraplatysmal plane. The pla- are pulled laterally and closed with the resulting
tysma may be plicated at the anterior margins of scar appearing similar to a Z-plasty closure.
the muscle to reduce tension across the skin at
the incision site. Two acutely angled incisions Grecian Urn Technique
are made at the superolateral aspect of the el-
The Grecian urn technique was described by Far-
lipse, and excess skin is removed. The resulting
rior and colleagues in 1990 and has since been
corners of the lateral skin flaps are advanced used with excellent results. As such, it is the au-
superomedially to close into the configuration of thors’ preferred approach. Markings are planned
a T-shaped line (Fig. 4). The vertical limb of the
with a single vertical fusiform excision and hori-
T may be broken up with Z-plasties if needed, zontally oriented fusiform excisions superiorly
with the lateral arms of the Z-plasty measuring 3 and inferiorly. The vertically oriented ellipse of
to 3.5 cm in length and the transverse portion of
skin is marked by first pinching the skin together
the Z-plasty oriented within the suprahyoid
at the level of the cervicomental angle. The supe-
crease. If the inferior portion of the vertically ori- rior apex of this ellipse is positioned at the sub-
ented ellipse is at or above the suprahyoid crease,
mental crease. The inferior apex is positioned at
a Z-plasty closure is unnecessary.
the level of the thyroid notch or extended further
Fig. 4. Vertically oriented elliptical excisions with a T-closure. (A) A vertically oriented central ellipse of skin is
marked and removed with the apex of the ellipse at the submental crease; the inferior point varies depending
on the pathologic characteristics. (B) An acutely angled triangle of skin is then removed between the submental
crease and the superior portion of the ellipse. Platysma and fat are then addressed. (C) The skin edges are reap-
proximated and closed. (D) The final closure is T shaped.
358 Gu et al
Fig. 5. Bilateral hemi-ellipse. (A) A vertically oriented ellipse is marked. A midline vertical incision is made con-
necting the apices of the ellipse. The superior portion of one-half of the ellipse is excised together with under-
lying excess fat. A similar procedure is performed on the inferior segment of the contralateral half of the ellipse.
Once undermined, platysmal plication and excess fat removal can be performed. (B) Final closure leaves a scar
similar to a Z-plasty.
inferiorly if needed depending on the amount of across the skin closure and to visually disrupt the
skin removal required. The superior and inferior linear scar, allowing for further enhancement of
horizontally oriented ellipses are marked at the the cervicomental angle. The width of the ellipse
level of the apices of the vertically oriented ellipse. serves to reduce excess skin in a horizontal plane,
A 60 Z-plasty with limbs measuring 1 to 1.5 cm is and superior and inferior ellipses remove excess
placed at the cervicomental angle, with the result- skin in a vertical plane, reducing the vertical length
ing Z-plasty oriented horizontally within the cervi- of the scar. The Lazy-H, in contrast, only removes
comental angle. Care should be taken to skin in a horizontal plane and accordingly does not
preserve vascular supply to the tip of the Z-plasty affect the vertical length of the resulting scar.
flaps to avoid necrosis.
After incisions are created, dissection is per-
Postoperative Care and Complications
formed laterally in a supraplatysmal plane. Exces-
sive subcutaneous fat is removed in a tapered The authors recommend wrapping the neck and
fashion. Dissection should be carried laterally until submentum with a secure and moderately tight
the free platysmal edges are identified. The medial dressing for 24 hours postoperatively. In their
edges of the platysma are then plicated in the practice, they remove the dressing and examine
midline from mentum to thyroid notch. The pla- patients in clinic on the first postoperative day.
tysma can be suspended to the underlying hyoid The patient is directed to avoid shaving for 2 weeks
bone fascia to increase the definition of the cervi- postoperatively and thereafter to use only an elec-
comental angle. Alternatively, two superiorly tric razor for an additional 2 weeks to minimize risk
based platysmal flaps may be created by making of injury to the incision. Fortunately, a beard actu-
a horizontal incision in the platysma at the level ally helps to camouflage the scar during the heal-
of the hyoid bone on either side of the neck. The ing phase; in fact, patients are encouraged to
superiorly based flaps are rotated across the wear a beard for as long as possible to camouflage
midline and imbricated over one another to create the scar. The scar fades over weeks to months.
a strong sling for submental support and correc- Overall, complications are rare and mild. Pain,
tion of platysmal banding. The skin is then closed edema, erythema, postinflammatory pigmentary
in layers. The final incision seems similar in shape changes, infection, bleeding, and scarring are
to an ancient Grecian urn (Figs. 6 and 7). possible risks. The rate of hematoma in neck lift is
The Grecian urn technique has several advan- approximately 3%, with risk factors including hy-
tages. The Z-plasty functions to reduce tension pertension, male gender, and use of anticoagulant
Fig. 6. Grecian urn technique. (A) A vertically oriented ellipse of skin is marked. The superior apex is positioned at
the submental crease, and the inferior portion varies but may extend to the thyroid notch or below. Symmetric
horizontally oriented ellipses are marked at the inferior and superior vertical ellipse apices. The final incision
marking seems similar to an ancient Grecian urn. A 60 1.0- to 1.5-cm Z-plasty is marked at the cervicomental
angle. (B) Incisions are created, and undermining is performed in a supraplatysmal plane. The platysma is plicated
to the thyroid notch. The skin is closed according to the indicated arrows. (C) The final closure results in scars
generally well disguised in natural submental creases. (D, F) Preoperative frontal and profile views. (E, G) Post-
operative frontal and profile views. Rhinophyma treated concurrently.
medications or supplements.17 Drains and tissue rhytidectomy.18 A prospective, randomized

sealants can be used in aging neck surgery. Hema- controlled trial demonstrated no influence on post-
tomas after neck rejuvenation are rare and difficult operative hematoma occurrence by the use of
to study. Nevertheless, current evidence has not drains in cervicofacial rhytidectomy.19 If an expand-
demonstrated an advantage of using drains or tis- ing hematoma is encountered in the postoperative
sue sealants to decrease the rate of hematomas. period, immediate evacuation of the hematoma
A meta-analysis demonstrated no statistically sig- and exploration of the operative site for hemostasis
nificant benefit from the use of tissue sealants in is essential to prevent airway compromise or flap
Fig. 7. Grecian urn before and after photos. (A, C) Patient 1 before. (B, D) Patient 1 after. (E, G) Patient 2 before.
(F, H) Patient 2 after. (I, K) Patient 3 before. (J, L) Patient 3 after.
360 Gu et al
necrosis. Wound infection after rhytidectomy in 2. Kamer FM, Lefkoff LA. Submental Surgery A Gradu-
general is rare with an incidence of 0.6%, and pro- ated Approach to the Aging Neck. Arch Otolaryngol
phylactic antibiotics are not typically prescribed un- Head Neck Surg 1991;117:40–6.
less there is a concern for methicillin-resistant staph 3. Shadfar S, Perkins SW. Anatomy and Physiology of
aureus colonization.20 Scar revision and laser resur- the Aging Neck. Facial Plastic Surgery Clinics of
facing can be used to minimize scar visibility if North America 2014;22:161–70.
needed. Hyperdilute botulinum toxin injections 4. Adamson PA, Litner JA. Surgical Management of the
directly into the scar every few weeks can further Aging Neck. Facial Plast Surg 2005;21:11–20.
heal the scar, with minimal risk to the patient no mat- 5. Thomas JR, Dixon TK. Preoperative Evaluation of the
ter the patient’s skin type. Aging Neck Patient. Facial Plastic Surgery Clinics of
North America 2014;22:171–6.
6. Jordan JR. Direct cervicoplasty. Facial Plast Surg
SUMMARY
2012;28:52–9.
Direct neck lift offers an excellent alternative to full 7. Guyuron B, Sadek EY, Ahmadian R. A 26-year expe-
rhytidectomy in men seeking neck rejuvenation rience with vest-over-pants technique platysmarrha-
and willing to tolerate a visible anterior neck inci- phy. Plast Reconstr Surg 2010;126:1027–34.
sion. Surgical exposure to the underlying fat, pla- 8. Marshak H, Morrow DM. ‘The stork lift’: A circumoc-
tysma and digastric muscle, and hyoid bone as cipital extended neck-lift. Aesthetic Plast Surg 2008;
well as skin removal allow for neck recontouring 32:850–5.
and rejuvenation. Many surgical approaches and 9. Gryskiewicz JM. Submental suction-assisted lipec-
techniques have been described; the authors pre- tomy without platysmaplasty: pushing the (skin) en-
fer the Grecian urn with Z-plasty at the cervico- velope to avoid a face lift for unsuitable candidates.
mental angle and platysmal plication. Given the Plast Reconstr Surg 2003;112(5):1393–405.
degree of variation of submental fullness with 10. Zins JE, Fardo D. The ‘anterior-only’ approach to
which patients present, it is beneficial to be familiar neck rejuvenation: An alternative to face lift surgery.
with several different techniques to address the Plast Reconstr Surg 2005;115:1761–8.
submental and submandibular areas. 11. Gonzalez R. The LOPP-lateral overlapping plication
of the platysma. An effective neck lift without sub-
CLINICS CARE POINTS mental incision. Clin Plast Surg 2014;41:65–72.
12. Bitner JB, Friedman O, Farrior RT, et al. Direct Sub-
mentoplasty for Neck Rejuvenation. Arch Facial
Plast Surg 2007;9:194–200.
13. Cronin TD, Biggs TM. The T-Z Plasty for the Male
Direct neck lift approaches may offer signifi-
‘Turkey Gobbler’ Neck. Plast Reconstr Surg 1971;
cant benefit for patients who may not desire
full rhytidectomy. 47:534–8.
14. Ehlert TK, Regan J, et al. Submental W-Plasty for
Patient selection, preoperative screening, Correction of ‘Turkey Gobbler’ Deformities. Arch
and counseling are important to address in
Otolaryngol Head Neck Surg 1990;116:714–7.
order to obtain optimal results.
15. Miller TA, Orringer JS. Excision of Neck Redundancy
An overview of many of the most commonly with Single Z-Plasty Closure. Plast Reconstr Surg
used direct cervicoplasty approaches is dis- 1996;97:219–21.
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16. Hamilton JM. Submental lipectomy with skin exci-
sion. Plast Reconstr Surg 1993;92:443–7.
17. Batniji RK. Complications/Sequelae of Neck Rejuve-
ACKNOWLEDGMENTS nation. Facial Plastic Surgery Clinics of North Amer-
ica 2014;22:317–20.
Figures courtesy of Marielle Mahan, MD. 18. Por YC, Shi L, Samuel M, et al. Use of tissue sealants
in face-lifts: A metaanalysis. Aesthetic Plast Surg
DISCLOSURE 2009;33:336–9.
19. Jones BM, Grover R, Hamilton S. The efficacy of sur-
The authors have nothing to disclose. gical drainage in cervicofacial rhytidectomy: A pro-
spective, randomized, controlled trial. Plast
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20. Zoumalan RA, Rosenberg DB. Methicillin-Resistant
1. Adamson JE, Horton CE, Crawford HH. The surgical Staphylococcus aureus-Positive Surgical Site Infec-
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Di rec t Neck Lift for M en

INTRODUCTION recovery. The disadvantages of the direct

Facial Plast Surg Clin N Am 32 (2024) 353–360

DISCUSSION preoperatively. Although it is possible to perform re-

Elliptical Excision lateral flaps are pulled only in a horizontal vector,

Vertically Oriented Elliptical Excision with a Bilateral Hemi-Ellipse

medications or supplements.17 Drains and tissue rhytidectomy.18 A prospective, randomized

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