Deep neck lift

What it is

• The platysma is the thin sheet of muscle under the neck skin; its inner edges form the vertical bands of an aging neck (PMID 7433553, PMID 37186556).
• Under it lie deep fat, the two small digastric muscles under the chin and the submandibular glands below the jaw. Tightening skin and platysma over a full deep neck does not correct it (PMID 36563673, PMID 30268239).
• A deep neck lift opens the platysma and reduces whichever of these structures is too full, then closes and tightens the muscle (PMID 33543747, PMID 30268237).
• In O'Daniel's measured series most of the tissue removed came from under the platysma: deep fat was reduced in nearly all patients, the gland in about three in four and the digastric muscles in about two in three (PMID 33543747).

Where it came from

• In 1980 Ellenbogen and Karlin set out visual criteria for a youthful neck and advised removing the fat under the platysma in heavy necks (PMID 7443846).
• The same year de Castro mapped how the two halves of the platysma meet or stay apart under the chin (PMID 7433553). In 1990 Feldman described the corset platysmaplasty, a long midline stitch that tightens the muscle down the neck (PMID 2304983).
• In 1997 Connell described trimming a bulky digastric muscle (PMID 9145126), and by 2003 cadaver work had mapped a safe path for reducing the part of the gland below the jaw (PMID 12973234).
• In 2015 Mendelson reported a large series of gland reductions: complications were comparable to a standard neck lift, with the specific risk of bleeding deep in the neck (PMID 25989302).
• A 2023 cadaver study showed the platysma is segmental, with separate nerve supplies, which explains recurrent bands and temporary lower lip weakness after neck lifts (PMID 37186556). In 2023 O'Daniel's presentation on safe steps for gland reduction won the gold medal for facial oral communications at the ISAPS Olympiad in Athens, and Ozan Sozer's "Strategies in Neck Lift" won silver (https://www.isaps.org/articles/isaps-blog/2023/isaps-olympiad-athens-2023-award-winners/). In 2026 O'Daniel and Duff published that method as the seven-step Carina technique (PMID 42759497).

Who it suits

• A neck that stays full or blunted because of deep fat, large or drooping glands or bulky digastric muscles (PMID 36563673, PMID 30268239).
• Ultrasound before surgery can measure the deep fat, and the thickness predicted how much was removed (PMID 41468305).
• Second neck lifts: recurrent bands, persistent fullness under the chin and drooping glands are the usual reasons (PMID 41673281).
• After non-surgical neck treatments (fat-dissolving injections, fat freezing, radiofrequency devices, threads), surgeons found scarring and lost tissue planes; nearly all such patients needed a deep neck lift, and most had some contour irregularity afterward (PMID 40712094).
• Some necks need only a front approach: a lift through a small cut under the chin, without facelift incisions (PMID 15861088, PMID 32436583).

How it is done

• Through an incision under the chin, the surgeon lifts the skin and opens the platysma (PMID 15861088, PMID 33543747, PMID 42759497).
• Deep fat is trimmed; a bulky digastric is trimmed or its two bellies stitched together to reposition the hyoid bone; the part of the gland that hangs below the jawline is reduced (PMID 33543747, PMID 12973234).
• The nerve branch to the lower lip lies outside the gland capsule above the gland's lower edge, and nerves that also supply the lower lip muscle run in the neck platysma, so surgeons plan the dissection around them (PMID 12973234, PMID 37186556).
• The Carina technique sets seven steps: incision placement, wide lifting of the platysma, a clear line of sight, an open working space, freeing the gland, controlled reduction and repair of the gland capsule (PMID 42759497).
• Vessel-sealing devices are used to reduce the gland with little bleeding (PMID 38546581, PMID 42022460).
• The platysma is then closed in the midline, cut across to release bands, or suspended behind the ear, often fixed to the mastoid to deepen the angle under the jaw (PMID 2304983, PMID 27307341, PMID 39212629, PMID 37767973).

Results and how long they last

• Digastric trimming led to less neck tightness and fewer revision neck lifts (about 1 in 25 against about 1 in 11), with no more trouble swallowing or speaking (PMID 41283798).
• Neck bands: after complete transection, about half of patients were band-free at one year in one series (PMID 27307341); another series saw no band recurrence at five years (PMID 37737877). Pooled transection studies found recurrence in about 1 in 70 (PMID 39406360).
• A front-only neck lift improved the neck by one or two grades (PMID 15861088), and patients looked about 3.6 years younger at two years (PMID 32436583).
• Most deep neck studies rely on surgeon judgment; few use objective measures (PMID 39652837).

Risks and how surgeons lower them

• Lower lip weakness: temporary weakness of the lower lip is common after work under the chin. In the Carina series it affected both sides in every front neck lift patient and recovered unevenly in about 1 in 14 (PMID 42759497). In another large series it affected about 1 in 18 (PMID 27356946).
• Nerve injury with gland reduction: pooled data across six approaches found weakness of the lower lip nerve in about 1 in 10 and any complication in about 1 in 7, highest with approaches from behind the ear (PMID 41092483). Single-surgeon series report lower rates, with no permanent nerve injury (PMID 42137253, PMID 42695798).
• Bleeding: bleeding deep in the neck after gland reduction can compress the airway, and one early series had a potentially fatal case (PMID 25989302). Surgeons now control it with structured steps and vessel-sealing devices: the Carina series had no uncontrolled bleeding and no hematoma (PMID 42759497, PMID 38546581).
• Saliva collection (sialocele): about 1 in 22 in an early series, all resolved by three months (PMID 25989302); about 1 in 75 in a pooled review (PMID 31970454); none in the Carina series (PMID 42759497).
• Dry mouth: no patient reported permanent dry mouth after partial gland reduction, and temporary dry mouth was rare (PMID 25989302, PMID 42759497).
• Across deep neck studies, nerve weakness ranged from under 1 in 100 to about 1 in 8 and hematoma from under 1 in 100 to 1 in 25 (PMID 39652837). A large subplatysmal series had no hematoma under the muscle (PMID 27356946).

Recovery

• Saliva collections and temporary lower lip nerve weakness after gland reduction all resolved within three months in an early series (PMID 25989302).
• Neck tightness was less common when the digastric muscles were trimmed (PMID 41283798).

Questions to ask a surgeon

• Is my fullness from skin, fat above the muscle, or structures below it? (PMID 36563673)
• Will you reduce my glands or digastric muscles, and why? (PMID 33543747)
• How do you prevent bleeding deep in the neck? (PMID 42759497)
• How often do your patients have lower lip weakness, and how long does it last? (PMID 41092483)
• I have had neck injections or devices; how does that change my surgery? (PMID 40712094)

Open questions

• Gland reduction nerve risk: about 1 in 10 pooled across approaches (PMID 41092483) against lower rates in single-surgeon series (PMID 42759497, PMID 42137253).
• Bands: recurrence after transection ranges from none (PMID 37737877) to about half at one year (PMID 27307341).
• Segmental nerve supply and targeted denervation as a band strategy (PMID 37186556, PMID 40456286, PMID 41568933).
• Outcome reporting: few deep neck studies use objective measures (PMID 39652837).
• The cervical nerve branch to the platysma runs under the deep neck fascia (PMID 38748536).

Terms

• Platysma: the thin neck muscle under the skin that forms the neck bands (PMID 7433553).
• Subplatysmal fat: fat under the platysma in the central neck (PMID 33543747).
• Deep cervicoplasty / deep neck lift: a neck lift that reduces structures under the platysma (PMID 39652837).
• Submandibular gland (SMG): the salivary gland under the jaw; partial reduction removes the part below the jaw edge (PMID 12973234).
• Sialocele / sialoma: a saliva collection after gland surgery (PMID 25989302).
• Anterior digastric: paired muscle bellies under the chin, trimmed or stitched together in neck lifts (PMID 9145126).
• Corset platysmaplasty: midline platysma stitching along the full neck (PMID 2304983).
• Marginal mandibular / cervical branch: facial nerve branches that move the lower lip; injury causes lower lip weakness (PMID 37186556).
• LigaSure: a bipolar vessel-sealing device (PMID 38546581).
• Carina technique: O'Daniel's seven-step gland reduction (PMID 42759497).

Papers