"As many aesthetic patients differ in their set goals, a well-thought-out surgical approach particularly tailored to an individual's needs should be clearly established and discussed in great detail in order to better satisfy patients and help them reach their attainable aesthetic outcomes," says Jonathan Sykes M.D., F.A.C.S., professor and director, facial plastic surgery, UC Davis Medical Center, Sacramento, Calif., and current president of the American Academy of Facial Plastic and Reconstructive Surgery.
A patient can be dissatisfied with the cosmetic result following necklift surgery for a variety of reasons, Dr. Sykes says. A patient may have had a very successful cosmetic neck surgery, but personal expectations weren't met because the expectations were greater than the surgery or the surgeon could provide."There is usually an indelible emotional overlay in patients undergoing a revision neck surgery. They have already undergone a primary procedure, which in their opinion has not satisfactorily addressed all of their cosmetic issues. They arrive at the surgeon with a set of physical issues that they want corrected. However, there is also an overlying set of emotional issues related to the primary surgery and its lack of satisfaction. Therefore, the surgeon not only has to be a good technician and diagnostician, but also a little bit of a counselor in order to ultimately make the patient happy," Dr. Sykes says.
In all cases, it is important that the patient feel understood and accepted, Dr. Sykes says. They must let the patient know that they are listening and accepting of the problem. After allowing the patient to fully express concerns, the physician can then determine the anatomic cause of the problem. Only after a detailed analysis should the surgeon establish an approach and technique suitable to create a more sculpted neck.
SURGICAL CHALLENGES One of the main goals of neck surgery is to achieve an angular and sculpted neck. This can be difficult, however, due to many patients' physical limitations. These limitations can include exceedingly crepey or wrinkled skin due to sun damage, smoking, a genetic predisposition or a combination of these factors.
Other features that can make a necklift challenging include a very heavy neck. According to Dr. Sykes, the heavy neck seen in some patients can be due to very dense soft tissue or excess fat. In all cases, revision surgery can be performed, but realistic expectations should be established and documented.
"It is not uncommon that patients will ask for and expect aesthetic results which are simply unattainable. In such scenarios, it is crucial to explain to the patient that their aesthetic look could be improved. However, a perfect aesthetic outcome vis-à-vis their aesthetic expectations may be unlikely," Dr. Sykes says.
NECKLIFT OPTIONS When performing a primary or secondary necklift surgery, Dr. Sykes says he often uses a submental and/or a postauricular approach.
A submental approach can entail the removal of fat through a direct excision or liposuction, with or without the removal of excess skin. Depending on the degree of skin laxity, the removal of excess skin may be necessary and may require a slightly longer excision, resulting in a longer scar.
"In those patients with exceedingly crepey skin, I often have to design specific incisions (with skin excision) for that particular patient in order to address their excess skin. I will often take out some central neck skin in the submental region in order to achieve a tight enough looking result or a result that coincides with the aesthetic goal of the primary procedure," Dr. Sykes says.
In a submental approach, Dr. Sykes often performs the platysmaplasty by tying the central muscles of the platysma together in order to tighten those muscles like a hammock over the neck, resulting in an improved definition of the neck. Depending on the degree of neck laxity, however, a postauricular approach may be additionally required to achieve an improved lifting of the neck.
INDIVIDUALISM COUNTS When approaching a patient desiring a revision neck surgery, Dr. Sykes said it is crucial to establish the reasons why the patient wants the surgery, which can include missed expectations or because the patient has physical limitations that may render the necklift desired extremely difficult — if not unachievable.
"Surgeons should master their routine but not allow routine to be their master," Dr. Sykes says. "You should look at each patient differently and set up cosmetic goals with them and carefully choose a tailor-made surgical approach, because all patients are physically different and will likely have different challenges to overcome."
In cases in which patients are dissatisfied from a primary surgery and realistic expectations are not achieved through consultation, Dr. Sykes says he believes surgeons should proceed with caution. It is unlikely that any additional surgery will satisfy these patients; in fact, it may cause more damage on an emotional level.
"Despite all of these cautions, revision neck surgery can often be very gratifying for both the patient and the physician. The surgeon must be extremely cautious in their chosen surgical approach and exercise careful patient selection," Dr. Sykes says.
Disclosures: Dr. Sykes reports no relevant financial interests.