What the research shows
Several structures under the platysma can make the neck look heavy: deep fat, fat between the neck muscles, the front bellies of the digastric muscles, the submandibular salivary glands and the tail of the parotid gland (Bravo 2018). A prominent submandibular gland can spoil the neck even after a deep plane facelift and tightening of the platysma (Shauly 2026), and removing surface fat alone is not enough for many patients with fuller necks (Morel 2025). Imaging shows the gland sits lower with age while its total size stays the same, so a drooping gland is a main cause of fullness under the jaw (McCleary 2022).
The main risk is weakness of the lower lip, from injury to the nerve branch that pulls the lip down (the marginal mandibular nerve). Across published gland reduction studies it is the most common complication, at about 1 in 10 (Shauly 2026), and it is usually temporary: an earlier review found no permanent nerve damage and no lasting dry mouth (Benslimane 2020). Bleeding deep in the neck is rare but serious, because it can press on the airway; one surgeon's series also found more nerve weakness in second neck lifts and occasional saliva collections, all of which resolved within three months (Mendelson 2015). Complications usually resolve within a few months, and results improve with the surgeon's experience (Morel 2025).
A seven-step method for gland reduction, used in a large single-surgeon series, had no saliva collections and no hematomas after surgery. Every patient who had the front-of-neck approach had temporary lower lip weakness on both sides, and recovery was uneven in about 1 in 14 (O'Daniel 2026). In another large neck lift series, most patients had work below the platysma, lower lip weakness affected about 1 in 18, and no deep hematoma occurred (Auersvald 2017).
Removing the front of the digastric muscles did not affect swallowing or speech, and it lowered both the sense of neck tightness and the need for a second neck lift (Gray 2026). Imaging shows these muscles shrink with age, so their bulky look may come from changes in the tissue around them (McCleary 2023).
Where surgeons disagree
- A dropped gland or a larger one. One imaging study found descent with no change in total size (McCleary 2022). A study that scanned the same adults years apart found the gland grows mostly before 40 and with weight gain (Sawan 2021), and a cadaver study found no sign of a dropped gland even in the oldest specimens (Raveendran 2012).
- Reduce the gland or lift it. Some surgeons reduce the gland (Shauly 2026). Others hold it up with a stitched sling (Guyuron 2008) or use an extended SMAS lift that nearly removed the gland's visible bulge while leaving the gland in place (Heffern 2026).
- Deep or traditional neck lift. Satisfaction after deep neck lifts was high, but they caused more nerve weakness than traditional neck lifts in a review (Chinta 2025).
What is new
- A vessel-sealing instrument used to cut the gland prevented bleeding and hematoma, and the lip weakness that followed recovered within six months (Basaran 2025).
- Botulinum toxin is now the main way to prevent and treat saliva leaks after deep dissection (Santos 2025).
- Stepwise operative methods aim to make gland reduction safer and repeatable for surgeons with less training in it (O'Daniel 2026).
What is still unknown
- How results hold over many years. Studies vary in technique and reporting, and reviewers call for prospective studies (Shauly 2026).
- How to measure the result. Few deep neck studies use objective measures (Chinta 2025).
Key papers
- Guyuron 2008: suspended normal-sized dropped glands instead of cutting them.
- Mendelson 2015: set out the specific risks of gland reduction, including deep neck bleeding.
- Auersvald 2017: a large series of neck lifts with work below the platysma.
- Bravo 2018: described each deep neck structure that can be reduced.
- McCleary 2022: imaging showed the gland drops with age without growing.
- Basaran 2025: vessel-sealing gland excision without bleeding.
- Shauly 2026: pooled gland reduction results and risks by approach.
- Gray 2026: digastric muscle removal lowered neck tightness and revisions.
- O'Daniel 2026: a seven-step method for gland reduction with no postoperative hematomas.