Direct Neck Excision and Z-Plasty
Men with sagging necks are a unique challenge for the facial plastic surgeon. Unlike in women, where traditional facelift incisions may be hidden around the ears, most men wear shorter hairstyles which may make traditional incision lines more visible. Further, men’s skin skin is much heavier than women’s and tends to sag earlier after traditional facelifts. Finally, men who undergo traditional facelifts often find themselves shaving under and behind their earlobes due to the lifting of bearded skin into these areas.
A better solution in men, then, is the Direct Neck Excision with Z-Plasty. In this procedure, sagging skin, muscle, and fat are removed along the front of the neck, and the incision is closed into a large Z shape to improve healing. This procedure, properly performed, provides the best and most durable rejuvenation possible for the male neck, without the above downsides of traditional facelifting.
Occasionally, women are also a candidate for this procedure. Good female candidates tend to have extreme “turkey gobblers” without much jowling along the jawline. Direct Neck Excision and Z-Plasty can also be a good finishing touch for a tiny bit of remaining neck looseness after previous facelifting surgery.
While this procedure does leave a permanent Z-shaped incision line on the neck, it usually heals very well, with most of it hidden under the chin and in the neck creases. This incision line is often more socially acceptable to most men – while traditional facelift incisions are obviously from a cosmetic procedure, the Z-plasty incision can be attributed to almost anything – a cyst, a thyroid/voicebox procedure, etc.
As with most of our surgical procedures, Dr. Nayak performs the majority of direct neck excision and z-plasty procedures in our in-office AAAHC-accredited operating suite under local anesthesia or mild sedation. For patients who would like to be more deeply sedated or fully asleep, Dr. Nayak prefers Frontenac Surgery and Spine Care Center or St. John’s Mercy Hospital.
During your consultation for z-plasty surgery, Dr. Nayak will ask you what about your middle and lower face bothers you, and may also ask you to talk about other, related areas of your face, such as your skin tone, facial hollowing, neck fullness, or cheek position. Dr. Nayak will likely ask you to point out, very specifically, what you’d like to see changed. Identifying exactly what needs to be addressed is the cornerstone of good results!
Dr. Nayak will then review your medical history form, and may ask for some additional information from you. Current and past smoking habits, or the use of nicotine gum or patch products, are especially important to mention to Dr. Nayak during this part of the consultation as nicotine dramatically reduces the chances of proper healing. Dr. Nayak will also pay special attention to parts of your medical history that need to be considered carefully when undertaking neck surgery, such as uncontrolled high blood pressure, or any medications or supplements you may take that thin the blood. In general, all over-the-counter pain/fever reducers (except Tylenol) are off-limits for 2 weeks before and after neck surgery, as are ginkgo biloba, St. John’s Wort, or high doses of fish oil, flax seed oil, or vitamin E.
The Physical Examination
Dr. Nayak will then examine your face and neck to determine exactly what must be corrected to achieve optimum results. Good candidates for direct neck excision and Z-plasty surgery have a large, loose, “turkey gobbler” and have a history of good scar healing. Dr. Nayak will look for old scars on your face, neck, and arms to judge your healing tendencies, and will show you, with a marker on your neck skin, exactly where the permanent, Z-shaped incision scar will be.
In addition, should you desire improvements of the eyelids, brows, chin, or earlobe areas to achieve balanced results. Dr. Nayak will take a few moments to discuss these options with you to make sure they meet your personal esthetic goals.
The Preoperative Visit
Once you have decided to undergo lower face or neck lifting surgery, Dr. Nayak’s staff will help you schedule your surgical date, and, about 2 weeks preceding that, a preoperative visit. Expect to spend about 90 minutes in the office on the day of your preoperative visit. During this visit, you will be educated on before instructions, after instructions, and prescriptions. Written copies of all of these will be given to you at this visit, as well, and you will be able to fill your prescriptions ahead of time. You will also be reminded at this time to avoid for 2 weeks before and after surgery any medications and supplements that thin the blood.
Also at the preoperative visit, your private preoperative photographs will be taken, the surgical consent form will be read to you, and you will have an opportunity to discuss with Dr. Nayak any questions you still have remaining. Finally, at the conclusion of this visit, the balance of your surgical, facility, and anesthesia fees will be due.
The Surgical Visit
In general, you will be asked to arrive at 7:15 AM the morning of your planned surgery. If you are having your surgery at an outside facility, you may be asked to arrive earlier. You should have nothing to eat or drink (not even water, candy, or gum) after midnight the night before your procedure. If Dr. Nayak prescribed antibiotics, oral sedatives, or if you take blood pressure medication in the mornings, you may take these with a small sip of clear water.
You will need an adult driver on the day of your surgery to bring you and to take you home. Your companion may wait in our comfortable reception area, watching TV, reading, and enjoying coffee, soda, and snacks. Alternatively, if your companion wishes to leave a cellular telephone number, we can call him or her with updates and also at the conclusion of the procedure.
Upon your arrival, Dr. Nayak’s staff will greet you and review your medical history, looking for any new changes since your initial consultation. Dr. Nayak and his staff will also confirm that they and you are in agreement about which procedures are to be performed, and those areas will be marked with you sitting upright in a chair. If you are a woman under 50 and have not been surgically sterilized, a urine pregnancy test may be performed. In any case, you will have one last opportunity to have last-minute questions answered and use the restroom, and will be escorted to our AAAHC-accredited surgical suite.
Once there, you will be positioned comfortably on your back, with pillows behind your knees and under your neck. Blankets are also available if needed. You may also bring your own iPod or CD’s, or listen to our choice of soothing music.
Painless blood pressure and oxygen monitors will be placed on your arm and finger, and massaging air-filled stockings will be placed on your legs and thighs to encourage excellent circulation while you are lying down. Most patients truly enjoy these stockings and find them very soothing.
Dr. Nayak and his staff will then perform one final “time-out” aloud to ensure they are about to embark on the appropriate procedure on the appropriate patient. Your neck will then be slowly, gently numbed with local anesthesia, and sterile towels will be placed around your face and neck.
By this time, most patients feel very relaxed. Once numb, the majority of patients actually fall asleep intermittently. Those who do not remain relaxed but awake, and Dr. Nayak and his staff get the welcome opportunity to talk with you during the procedure.
Dr. Nayak will begin the procedure by removing the marked, excess skin of the neck. He will then tighten the muscle layer of the front of the neck and meticulously close the neck incision into a large Z-shape.
Your Recovery – Day 1
At the conclusion of your procedure, Dr. Nayak will tell your companion how everything went, and he or she will have the opportunity to see you. You will be mildly bruised and swollen at this point, but neither will be visible due to a fluffy cotton dressing that will be wrapped around your forehead, cheeks, and under your chin. Your face, mouth, nose, and eyes will not be covered by the dressing. If you have had eyelid surgery, a thin layer of Vaseline may have been applied to the eyelid area.
You will be asked to spend 1 hour with us prior to being discharged. Dr. Nayak will call you the evening of the procedure to check on your progress, and you will also be given Dr. Nayak’s personal cellular phone number in case questions should arise after hours or on the weekends.
Your Recovery – Week 1
Most patients feel no pain whatsoever immediately after surgery. Many patients find they nap intermittently the first afternoon. Later in the evening, most patients report a feeling of tightness or soreness along the front of the neck
Most patients take their prescribed pain medication for 24-36 hours after the procedure, and then switch to Tylenol – all other over-the-counter pain preparations are off-limits. Many patients take Tylenol alone right from the start, while a few require the prescription pain medication for 3-4 days.
On the day after surgery, you will need a ride back to Dr. Nayak’s office, where he will remove your dressing and examine your face to make sure you are healing properly.
You will be able to shower and get all sutures wet the first day after surgery, as soon as you have your dressing removed. You will be asked to use intermittent cold compresses and sleep with your head elevated for the first few days.
On the 6th or 7th day after surgery, you will return to the office for a painless suture removal visit. If you have significant bruising remaining at this point, it may be treated with a laser to hasten its disappearance.
By the 7th day, women may wear makeup, men may shave, and almost everyone is “presentable” to run errands or go back to work. Especially easy bruisers, or patients over 65, may require another 2-3 days for most of the bruising to resolve. By 2-3 weeks, most people are “undetectable”. If you are not self conscious about being seen with bruising or sutures in place, or work from home, expect to be back to work within 3-4 days!
Your Recovery – Long Term
Over the ensuing weeks and months, you will find your incision lines, in a Z-shape in the front of your neck, heal gradually. By 3-4 months, the pinkness is generally gone and the incision line barely noticeable.
While duration of results depends on lifestyle, genetics, and ongoing skin care and sun protection, direct neck excision and z-plasty is the most long-lasting treatment available for sagging necks. It is not uncommon for results to last 7-10 years or even longer before touchups are required.