After Necklift Surgery and Possible Revision

Pretty swelling versus ugly swelling

It’s too early to make a decision on what revision to perform. There is no doubt that you have swelling still at 6-8 weeks. Even if the swelling is minimal, this is the type of “honeymoon swelling” that I often write about in my posts. The swelling is not an “ugly, postop” swelling, but the swelling is mild and makes the skin act thicker than the final result. This very mild swelling actually makes the 1-4 month appearance look better than the final result. Why? All of the wrinkles look better, as well as the texture and firmness of the skin. Often my patients marvel at their fast recovery, and the fact they don’t look horrible during the early post-op period. I curb their enthusiasm, and let them know this is not their final result. They can enjoy their short term “honeymoon swelling” as opposed to more aggressive facelifts which have abnormal swelling and distortions up to 5-6 months after surgery, before they see the final result. In the less invasive surgeries, they have a “honeymoon period” where as the aggressive surgeries usually have a “cocoon period” where they don’t look particularly good yet. If you compare both types of patients’ before and after photos after 1 year, you should be able to see significant improvement in both types. In the latter case with aggressive facelifts, they can look worse, than their final result, so they are simply happy to look more normal again. In the former case, with less invasive facelifts, often the patients like the early appearance more than their final appearance. Why? The slight swelling is actually adding volume to their faces. Pulling the face tighter will not add volume. It may stretch or distort the face more, the harder the surgeon tightens the face. Adding volume to the face with fat or fillers can help to take some of the slack out of the skin by making the skin and fuller, but without making it look tighter. I hope that makes sense.

It’s relative: Is that higher, or is this lower?

As the swelling comes down, the “puff” behind the chin crease should decrease, as well as the flat center and puffy sides appearance may also change, for the better or for the worse. But only time will tell. To jump into another revision surgery before the first surgery has had time to heal may end up in an unsatisfactory revision. Another possibility for a revision is if you have too much fat removed in the center which is causing the indented area under the chin, and the “sagging” sides are actually in the correct level. Only a face to face examination with your own surgeon will be able to determine if the center is at a normal level and the sides are sagging, versus the sides are normal and the center was overly defatted. Here is a link
regarding this liposuction under the chin: george-yang-doctor/lipo-under-chin-t142558.html

Simulation of youth

Of note, a necklift does not “recreate” your neck in youth. It’s a bit of smoke and mirrors, to make the neck look similar to a youthful neck. The skin is not any younger. The excess skin is removed, and redraped over the neck. The older skin stretched over the more contoured neck looks younger, but the skin may still be “crepey” when it is pinched or if the patient
flexes their neck forward. This means the surgeon is not anatomically restoring your neck in youth. By removing fat, sewing the muscle bands together, and removing excess skin, it looks more like a younger appearing neck, but the anatomy is different and the surgeon is relying on scar tissue to hold the different layers together. The muscle bands are flat against the neck in youth are naturally apart, but sewing the muscle bands together under the chin, helps to define the separation between the chin and neck area which appears youthful,
but is not the same as in youth. It is possible that you had more fat under your skin in youth, but as we age, we gain fat in different layers including within the muscles of the neck and tongue. If this is the case, no matter how much the surgeon tightens the overlying skin, muscle and fat under the skin, the “fatter muscles” of the tongue and neck cannot be defatted
through surgery, so a perfect replication of youth is impossible.

Another example is a tummy tuck. The excess skin and fat is removed, and a new belly button is made higher up on the smooth area of the abdomen. This makes the appearance of a flat belly, but when the patient regains feeling, when they touch around their belly button, they feel like they are touching an area higher up on their abdomen. So it is not a “restoration of youth” but more of a “simulation of youth.” Other people will see a flat tummy that the patient appeared to have had in youth, but they don’t realize that all is not how it seems.

Pins and Needles

The skin that was operated on during your facelift and necklift will be numb initially. During the subsequent months, the feeling will return initially as a pins and needles, as well as temperature sensations, similar to when your leg falls asleep, then when it “wakes up” you get the pins and needles sensation before you regain full feeling.

Question “For this type of revision do you think it’s possible to correct the hanging
under the chin area that I have? I believe everything you have diagnosed so far
is very accurate and I was wondering what approach you would take at this point
to correct the hanging muscle and although it’s early in recovery, today the 7
week mark, how do you know when the soonest opportunity for revision would be
indicated.”

When your neck finally settles after 6-9 months, there should be a solution to resolve the problem. I am not totally convinces that it is definitely hanging muscle, and throw in the possibility that there may be too little fat in the middle. As the miminal swelling goes down, sometimes the two areas that are hanging, actually can thin out into muscle bands.

The earliest I would consider revising is 9 months. Reoperating on a surgical site very early after surgery is a recipe for disaster. It can ruin the prior good work that was already accomplished. Immediately after any trauma, whether an accidental laceration or surgery, our bodies will create a zone of inflammation to “clean up” any bacteria or foreign bodies. If our skin is broken, it is usually due to a laceration, which is not clean. Before healing the laceration our bodies have natural mechanisms to “clean” and “disinfect” the wound before healing the skin. Surgery is performed in a sterile environment, but our tissues still go through the same inflammatory process not knowing that it was surgery and not an accidental cut. When our tissues are inflamed during the early healing process, sewing with a needle and thread these fragile, and friable (like wet tissue paper, tofu, or flan) tissues will only result in tearing through these tissues you are trying to tighten. Instead of making the area tighter, since the tissues can’t hold the sutures, it may actually loosen the area. As the operated area
heals, collagen fibers “knit” a layer of scar tissue which is tough and fibrous (like beef jerky.) If the surgeon waits until the tissues are more healed, the tougher tissues will hold the tightening sutures much better, and a more optimal revision can be performed.

Great Expectations: Difficult necks more often than not require a revision. I’ve performed enough facelifts to know when I encounter a patient with a difficult neck who will likely need a revision even before I perform the initial facelift. Not everyone needs a revision, but many of the difficult necks do want one. I am careful to explain this likely possibility, and show them examples of patients during the consultation and pre-op to further reinforce this possibility. Even if I anticipate and overtighten during the initial surgery, this can result in distortions on other parts of the face and still have the neck not be ideal.