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3 Anatomical Challenges in Surgical Neck Rejuvenation

The appearance of the neck plays a crucial role in the overall perception of youthfulness and attractiveness of the face. As people age, various changes occur in the skin, soft tissue, and underlying bone structure, leading to excess skin laxity, volume loss, and contour irregularities. These aging signs can make the face appear older and less attractive. Surgical procedures such as facelifts and neck lifts have become increasingly popular since the 1970s, largely due to advancements in the understanding of facial anatomy and improved surgical techniques, particularly those involving the superficial musculoaponeurotic system (SMAS). These procedures aim to restore the youthful features of the face, offering a more defined jawline, optimal cervicomental angle, and smooth, well-positioned skin and soft tissue volume.

However, achieving successful outcomes in facial rejuvenation surgery presents several challenges. Variations in individual anatomy and skin quality can make some cases particularly complex. Furthermore, the success of these procedures is not solely dependent on surgical technique; managing patient expectations through thorough evaluation and counseling is critical.

In this blog, we will delve into the complexities of neck lifting, focusing on the challenges posed by anatomical variations like the anterior hyoid, retrognathia, lax skin envelope, solar elastosis, and Ehlers-Danlos Syndrome.

I. Anterior Hyoid and Retrognathia

The challenge posed by anterior hyoid and retrognathia in surgical neck lifting is multifaceted, involving complex anatomical considerations that affect the cervicomental angle and jawline definition, which are critical for achieving aesthetically pleasing outcomes.

Anterior Hyoid Position

Hyoid Bone Anatomy

The hyoid bone is a horseshoe-shaped bone located in the midline of the anterior neck, typically at or above the level of the fourth cervical vertebra. Unlike most bones, the hyoid is not directly articulated with other bones; instead, it is suspended by the suprahyoid and infrahyoid muscles. Its position can vary significantly in both cranial-caudal and anteroposterior dimensions, influencing the cervicomental angle.

Impact on Cervicomental Angle

A high and posteriorly positioned hyoid bone is ideal as it allows the suprahyoid muscles to course horizontally, creating a sharp cervicomental angle typically measuring between 105 and 120 degrees. Conversely, a low and anteriorly positioned hyoid results in a vertical orientation of the suprahyoid muscles, leading to a more obtuse cervicomental angle. This anatomical configuration can contribute to the appearance of a double chin or a heavy neck, which can be particularly resistant to surgical correction.

Surgical Implications

Preoperative identification of the hyoid position is crucial. Patients with a low and anterior hyoid (classified as Dedo class VI) present a challenge because improving their cervicomental angle through traditional neck lifting techniques may be limited. Surgical techniques must be adapted to account for this structural limitation, and additional procedures such as chin augmentation with alloplastic implants or genioplasty may be necessary to achieve a satisfactory outcome.


Mandibular Anatomy

Retrognathia refers to a posteriorly positioned or underdeveloped mandible, which can be congenital or acquired with age due to bone resorption. This condition is often assessed using landmarks such as the lower vermilion border or the Frankfurt horizontal plane. Ideally, in men, the chin should project to a point along a line tangential to the lower vermilion border, and in women, it should be just posterior to this point.

Impact on Jawline Definition

Retrognathia results in a poorly projected chin and blunted jawline, exacerbating the difficulty of achieving a well-defined cervicomental angle. The inherent structural deficiency means that even with optimal surgical technique, the aesthetic improvement may be limited.

Surgical Considerations

Addressing retrognathia in the context of neck lifting requires a comprehensive approach. Preoperative evaluation should include assessing the need for mandibular augmentation to compensate for the deficient chin projection. This can involve the use of chin implants or orthognathic surgery, particularly in cases with associated malocclusion. During surgery, careful planning is needed to ensure that the improvements in the cervicomental angle are complemented by adequate chin projection, enhancing the overall facial balance and contour.

II. Lax Skin Envelope/Solar Elastosis/Ehlers-Danlos Syndrome

The presence of a lax skin envelope, solar elastosis, and conditions like Ehlers-Danlos Syndrome (EDS) significantly complicates surgical neck lifting. These factors introduce unique challenges that require a detailed understanding of the underlying pathology, precise surgical technique, and comprehensive preoperative planning to achieve optimal outcomes.

Lax Skin Envelope

Anatomical Characteristics

A lax skin envelope results from both intrinsic aging processes and external factors. With age, skin loses its elasticity and structural integrity due to decreased collagen and elastin production, increased collagen fragmentation, and diminished skin turgor. These changes lead to a redundant, sagging skin appearance that complicates surgical redraping.

Surgical Implications

1. Excessive Laxity Management:

  • Skin Excisions: More extensive skin excisions are often necessary to remove the redundant tissue and achieve a tight, smooth contour. However, this increases the risk of wound tension, which can lead to hypertrophic scarring or wound dehiscence.

  • Redraping and Tension: Ensuring adequate skin redraping without excessive tension is crucial. The balance between removing enough skin to create a youthful appearance and preserving enough skin to avoid undue tension is delicate and requires meticulous technique.

2. Supportive Measures:

SMAS and Platysma: Addressing underlying support structures, such as the superficial musculoaponeurotic system (SMAS) and the platysma muscle, is essential. Techniques such as SMAS plication or platysmaplasty can provide the necessary support to maintain the results of the neck lift.

Solar Elastosis


Solar elastosis results from chronic ultraviolet (UV) exposure leading to the degradation of collagen and elastin fibers in the dermis. Histologically, this condition is characterized by the accumulation of abnormal, basophilic elastotic material. Clinically, it presents as thickened, coarse, and deeply wrinkled skin.

Surgical Implications

1. Compromised Skin Quality:

  • Elasticity and Resilience: The compromised elasticity and resilience of skin affected by solar elastosis make it difficult to achieve smooth redraping. The skin may not conform well to the underlying structures, leading to an increased risk of irregular contours and suboptimal aesthetic results.

  • Healing and Scar Formation: Skin with solar elastosis is more prone to poor healing and scarring. The abnormal collagen and elastin fibers can lead to delayed wound healing, increased risk of infection, and more prominent scars.

2. Technical Modifications:

  • Preoperative Skin Conditioning: Preoperative skin treatments, such as chemical peels, laser resurfacing, or topical retinoids, can improve skin quality and elasticity, making it more amenable to surgical manipulation.

  • Advanced Suturing Techniques: Using advanced suturing techniques and tension-free closures can minimize the risk of wound dehiscence and hypertrophic scarring. Surgeons must be prepared to employ meticulous suturing and possibly utilize adjunctive measures such as tissue adhesives or silicone sheeting postoperatively.

Ehlers-Danlos Syndrome (EDS)


EDS is a group of genetic connective tissue disorders characterized by hyperextensible skin, joint hypermobility, and tissue fragility. Type I (classical EDS) involves mutations affecting type V collagen, resulting in exceptionally elastic, smooth, and fragile skin that bruises easily and lacks normal tensile strength.

Surgical Implications

1. Fragile Skin and Tissue Handling:

  • Gentle Handling: The fragile nature of EDS skin necessitates extremely gentle tissue handling to avoid intraoperative tearing and postoperative complications such as hematoma or skin flap necrosis.

  • Increased Bruising and Bleeding: Patients with EDS are prone to increased bruising and bleeding, requiring meticulous hemostasis during surgery and careful postoperative monitoring.

2. Wound Healing and Scar Formation:

  • Delayed Healing: The abnormal collagen structure in EDS leads to delayed wound healing and a higher risk of complications such as wound dehiscence and infection.

  • Scarring: EDS patients are at an elevated risk for abnormal scarring, including hypertrophic scars and keloids. Surgeons must employ advanced wound closure techniques and possibly use adjunctive therapies like silicone gel sheets or steroid injections to manage scarring.

3. Customized Surgical Plan:

  • Preoperative Counseling: Extensive preoperative counseling is essential to set realistic expectations and discuss the heightened risks associated with EDS. Patients should be informed about the potential for prolonged recovery and the need for careful postoperative care.

  • Supportive Measures: Considering additional supportive measures such as SMAS or platysma plication is crucial to provide the necessary structural support and improve long-term outcomes.

III. Prominent Submandibular Gland

Anatomical Considerations

The submandibular glands are major salivary glands situated beneath the lower jaw, within the submandibular triangle. In some patients, these glands can be prominent due to hypertrophy, ptosis, or congenital factors. A prominent submandibular gland can significantly impact the aesthetic outcome of neck lifting procedures, presenting unique challenges that demand a precise understanding of neck anatomy and advanced surgical skills.

Surgical Implications

1. Contour Irregularities and Aesthetic Outcomes:

  • Visibility and Bulging: A prominent submandibular gland can create noticeable bulging in the submandibular region, disrupting the desired smooth and defined jawline contour post-surgery. Even after successful skin redraping and muscle tightening, the gland's prominence can persist, leading to suboptimal aesthetic outcomes.

  • Asymmetry: Prominent submandibular glands can cause asymmetry in the neck's appearance, especially if one gland is more pronounced than the other. This asymmetry can be challenging to correct surgically and may necessitate additional interventions.

2. Technical Challenges in Gland Management:

  • Gland Excision: Partial excision or debulking of the submandibular gland can be considered to reduce its prominence. This procedure requires careful dissection to avoid injury to the surrounding structures, particularly the marginal mandibular branch of the facial nerve, which is in close proximity and critical for lower lip movement.

  • Subplatysmal Approach: Accessing the submandibular gland often involves a subplatysmal approach. This technique requires precise dissection beneath the platysma muscle, increasing the complexity of the surgery and the risk of nerve injury.

3. Increased Risk of Complications:

  • Nerve Injury: The marginal mandibular nerve runs superficially in the neck and is at risk during submandibular gland surgery. Injury to this nerve can result in lower lip weakness or asymmetry, significantly impacting the patient's functional and aesthetic outcomes.

  • Salivary Fistula and Sialocele: Surgical manipulation of the submandibular gland carries the risk of developing a salivary fistula or sialocele (salivary gland cyst), which can complicate the postoperative course and require additional management.

Adjunctive Techniques for Optimal Results

1. Platysmaplasty:

Combining submandibular gland management with platysmaplasty can enhance the neck contour by tightening the platysma muscle and reducing gland visibility. However, this combination requires careful planning to avoid excessive tension and potential complications.

2. Submental Liposuction:

In some cases, adjunctive submental liposuction can help contour the neck and improve the overall aesthetic outcome by removing excess fat that may obscure the gland's prominence. This technique, however, must be performed judiciously to avoid creating irregularities or compromising the overlying skin.

In conclusion, navigating the complexities of surgical neck lifting requires a thorough understanding of anatomical variations and their implications for surgical outcomes. By acknowledging and addressing challenges such as anterior hyoid and retrognathia, lax skin envelope and solar elastosis, Ehlers-Danlos Syndrome, and prominent submandibular glands, surgeons can tailor their approaches to each patient's specific needs. Through meticulous planning, precise surgical techniques, and attentive postoperative care, the hurdles posed by these anatomical nuances can be overcome, leading to enhanced functional restoration and aesthetically pleasing results. As advancements in surgical techniques and technologies continue to evolve, the management of these challenges will undoubtedly become more refined, further improving the outcomes of surgical neck lifting procedures.


Difficult Necks and Unresolved Problems in Neck Rejuvenation (2018)

Deep plane procedures in the neck (2015)

True Jewel Cosmetic Center (2024)

TeachMeAnatomy (2024)

Solar Elastosis / Actinic Elastosis (2019)

Acute Submandibular Sialadenitis (2022)


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