Dr. Little’s Techniques
Surgical Techniques for the Neck
Dr. Little is able to avoid direct surgery on the central neck structures (through a separate scar under the chin) in most patients, relying instead on the by-product effects of proper jowl lifting, along with a cable suture to the neck muscle in back; for the patient with a challenging neck and established muscle bands, he continues to section the platysma muscle, as he has these many years, but without need for the conventional scar under the chin.
Neck Lift without Chin Incision
When the volume excesses and redundancy of the jowl region are relieved by direct vertical suspension back to the low cheek, the jawline and neck are corrected in the majority of patients, without the need to operate directly on the central neck structures through a neck or under-chin incision. Resuspension of the fatty layer of the jowl brings with it the attached platysma muscle (the SMAS layer or structural “undercarriage” of the under jaw), as both layers move upward over the glide plane of the underlying premasseter space. In half the cases, the fatty layer under the chin is reduced by a brief micro-liposuction maneuver. In most necks, a single, buried (2-0 nylon) suture is added below the earlobe to aid in suspension of the back aspect of the platysma or neck muscle, as described by French plastic surgeon Daniel Labbé, M.D. (Labbé, D., Franco, R.G., and Nicolas, J. Platysma suspension and plastysmaplasty during neck lift: anatomical study and analysis of 30 cases. Plast. Reconstr. Surg. 117: 2001, 2006). Finally, when fixed muscle bands are present in the neck, these bands (with the remainder of the neck muscle itself) can also be divided (platysma myotomy), without the need for a central neck incision.
Cervicoplasty (Conventional Neck Lift)
In the extremely challenging neck (2%), conventional central neck surgery is added through an incision under the chin, bringing additional operative effort and time. The freeing of the skin must be extended across and under the neck (from ear-to-ear). Additional fat may need to be removed from the compartment deep to the platysma muscles. The deeper anterior digastric muscles may also require manipulation, and even a portion of the submandibular salivary gland may be removed. The platysma muscles are then sewn together in the midline (platysmaplasty), creating a muscle seam that further tightens the neck. Although Dr. Little performed such neck surgery routinely in most of his patients over many years, he now does so rarely, as he relies instead on resuspension of the jowl and associated structures to bring the neck back to a natural, more youthful position…that can then be boosted by other simpler maneuvers from the side.
Neck Lift without Facelift
Occasionally a patient requests that the neck be lifted with minimal change to the face. Such a neck lift alone can be accomplished in the younger patient by performing cervicoplasty through an incision under the chin alone (without a “facelift” type incision around the ear). In older patients with excess neck skin, however, the hidden short-scar incision around the ear must be added, but without any effort to bring change to the face itself. Sometimes, neck correction may be accomplished through the incision around the ear alone, without need for the incision under the chin with direct surgery on the central neck structures. Each patient is assessed individually for their own customized approach to neck correction without facelift.
Illustration: detail of Leonardo da Vinci, “Torso of a Man in Profile,” ca. 1490, Galleria dell’ Accademia, Venice