The Neck Best Thing

Announcer (00:02):
You are listening to Alabama the Beautiful with cosmetic surgeon, Dr. James Koehler and Kirstin Jarvis.

Kirstin (00:08):
Hey Dr. Koehler.

Announcer (00:09):
Hey Kirstin.,

Kirstin (00:12):
What do you want to talk about today?

Dr. Koehler (00:13):
I leave that up to you, whatever you want.

Kirstin (00:16):
How about the neck big thing?

Dr. Koehler (00:19):
The next big thing? What's the next big thing

Kirstin (00:22):
We're going to talk about necks today.

Dr. Koehler (00:24):
Necks? Alright.

Kirstin (00:25):
Yeah. What is the usual complaint of somebody who's coming to see you about their neck?

Dr. Koehler (00:30):
Most of the time people, they just don't like the turkey neck, you know the laxity there. Sometimes people complain about jowling as well, which really sort of a separate thing, but a lot of times it's a combination of jowling and neck laxity. Sometimes we have people concerned about the horizontal lines across their neck and those are kind of harder to treat. But those are kind of some of the main issues that people come in with.

Kirstin (00:54):
What causes those bands that you were just talking about?

Dr. Koehler (00:59):
Well, it is just everybody's skin elasticity is different. And as you age, some people, if they get a lot of sun exposure and maybe their genetics aren't as good, I mean they will tend to get these horizontal creases in the skin. I mean, it's a natural, I mean, those are the natural skin resting tension lines, and that's where we get the wrinkles. But some people just are more prone to them than others. And diet, exercise, genetics, sun exposure, all those things contribute. But that has more to do with skin elasticity. But when you have the overall general laxity in the neck, that is sometimes a combination of not just your skin texture and tone, but it actually has to do with the laxity of the muscles in the neck, the platysma muscle, which is muscle that runs from your chest all the way up into your face. And people will have what's called platysmal bands where they have these, it looks like individual sort of hanging areas of skin where really that can be sometimes the muscle edge that you're seeing. And so there are some things that people will try to do to pacify that because they don't want to have surgery. And there are a few things that you can do, but ultimately to really treat those, you're going to at some point have to do something surgical if you want to address it.

Kirstin (02:20):
You mentioned that genetics play a role, but are there things that we can do to prevent that kind of neck sagging from happening?

Dr. Koehler (02:29):
Well, I've seen things for all sorts of exercises that people say, oh, you should do these facial exercises to, it just doesn't work that way. So first of all, these muscles, and yes, I suppose you could strengthen them, but I've never seen that reverse the signs of aging for anybody. So I don't know, I mean, definitely protect your skin when you're out in the sun. I mean, try to avoid major damage. So getting major sunburns, being out in the sun a lot. If you're smoking, I mean, that's just going to age your skin tremendously, and have a decent diet, eat things that aren't just processed foods. So I mean, those are the things that you can do. You can't really change your genetics, but certainly the other things that influence our aging, which is diet, sun exposure habits, those kinds of things you can modify.

Kirstin (03:24):
Okay. Is there a certain age when you notice people start to come talk to you about these things?

Dr. Koehler (03:30):
Yeah, it usually starts in the forties. Most people in their forties are starting to complain a little bit of the laxity in the neck, but they don't really truly a lot of times have sagging there. So they're really not necessarily facelift candidates, although some of them are. And then it's really when we start seeing people in their fifties and sixties where not only is it now they've got neck laxity, but now they're starting to get jowls. And so now we're looking at a facelift, whereas in the forties we might be able to do an isolated neck procedure. And that's what we, if we're going to do something surgical, it's typically just isolated to the neck. Although I've had some people in their late forties that we are doing a full lower face and neck lift. So it just depends.

Kirstin (04:11):
All right. What about this? Do you want to talk about this?

Dr. Koehler (04:18):
What are you doing exactly?

Kirstin (04:21):
What about double chins? What can we do for double chins?

Dr. Koehler (04:24):
Well, I was going to tell you not to eat so many cheeseburgers, but I just don't know.

Kirstin (04:32):
That that's probably on my list actually.

Dr. Koehler (04:35):
Weight can sometimes be an issue with having a double chin. And so obviously weight loss might be a part of your regimen to help improve your neck contour. People who are heavier, and especially we all carry weight differently, some people will carry a lot of weight in their neck and then so have double chins related to that. Sometimes people just have a weak chin, they just don't have a prominence to their bony chin. And so because of that, they don't really have a good chin, neck contour may not necessarily be a double chin, but they just don't have a good jawline. And so in those cases, you can improve it with something like a chin implant. Chin implant will help give you more chin projection, give you more definition along the jawline. So sometimes it can be a simple thing like a chin implant and maybe a little mild neck liposuction. Though I tend to be really cautious in recommending liposuction to the neck these days. I mean, years ago I think we did a lot more frequently, but kind of realize now that maybe that's not maybe the best way to go for managing the neck.

Kirstin (05:39):
So we said liposuction is not always the best route to go. What other things do people come ask for that do not work?

Dr. Koehler (05:47):
Oh, treatments that don't work well?

Kirstin (05:48):
Mm-hmm.

Dr. Koehler (05:48):
Oh, there's a number of those, but lemme just back up to liposuction and let me just explain myself a little bit more. So I would say that liposuction is a simple procedure typically because a little tiny nick under the chin, maybe a little nick behind each ear, and you can do with a little liposuction cannula, you can remove superficial fat. But what people need to understand is that we carry fat in different layers. So underneath the skin is that subcutaneous fat and that is the fat that we're actually liposuctioning. And that layer of fat, although it can get fairly thick, it's typically not super, super thick. Then we have your platysma muscle and then up underneath that muscle, there's a lot of other muscles and nerves and arteries, and there's that deeper neck fat that sits below the muscles and that you can't treat with liposuction.

(06:40):
So it brings up a couple interesting problems. So if you've got a heavier neck patient, they're probably not a good liposuction candidate because they're probably carrying fat in both the superficial layer, but then also in that deeper layer. And with liposuction, you're only addressing that superficial layer of fat. And so ultimately you might get a disappointed patient because you didn't do anything to address the deeper fat. But to address the deeper fat, you have to do a surgical, a deep neck lift, or some people call it submentoplasty, but it's a procedure where you go underneath the muscle, identify those areas of fat that are contributing to a poor chin neck line and you remove that deeper layer of fat. Sometimes we also have to remove other deeper structures, like some people might have a little bit of a hanging submandibular gland, so we'll trim a little bit of the submandibular gland off just to remove these heavier structures that are preventing us from having a nice jawline.

(07:40):
So if you just treated it with liposuction, you wouldn't have treated any of those deeper structures and you would not get the benefit that you need. If you have it, let's say a thinner patient, well, those are also, yes, you can do liposuction, but I just said it's a thinner patient. So if they don't have a good chin neck contour and they are thinner, if you go ahead and do liposuction, it may look okay at first, but as we age that fat actually we lose fat in our face and we need that fat. And so some people, if they've had over aggressive liposuction when they're younger, can really end up with these sort of skeletonized looks. And I mentioned earlier about these platysmal bands. Well now there's less soft tissue coverage over that muscle. And so all those little irregularities of the muscle and the bands are even that much more noticeable.

(08:28):
So just to sort of rephrase that, thin patients are not good liposuction candidates, and that's true for merely a lot of even body liposuction. So if they don't have a good chin neck contour, it might require either chin implant or repositioning some of the deeper structures. So a submentoplasty or a deep neck lift, heavy patients, if we do liposuction, it's not going to give them enough. So we need to do a surgical procedure. And that would involve same things, chin implant, removing deep layers of fat, removing gland if necessary. So really the only good liposuction candidate is the person who's kind of right in between. They're not too thin, they're not too heavy, and maybe they just have a little bit of fullness. And as long as we do that liposuction conservatively, and don't try to overcorrect with liposuction, yes, you can do liposuction, but now all of a sudden you've got two groups of people, the thin and the heavy that are not good candidates, and you got to have that right in between candidate.

(09:24):
So it's not that we don't do liposuction, but typically it's a procedure where a lot of people try to do too much with it and you can end up with problems. So then what are the other non-surgical things that I see people coming in for? Well, I mentioned one or alluded to it earlier, which is Botox to the neck. I mentioned about the bands that people will get in their neck, and those can be sometimes from the platysma muscle that as we age, it just really, it starts to sag. It doesn't really do a whole lot. Men use it for shaving, tighten your neck to shave your skin. But anyhow, it's a useless muscle really. We don't use it for much of anything, but it starts to sag. And with those bands, you can inject Botox into it and it will kind of help relax those bands.

(10:12):
But it's a pretty sizable muscle, so the amount of Botox you have to put in is fairly significant. And I always ask people, have you done this before? And if they say yes, I'm like, well, how many units did you get? Because typically it's not, it's maybe at least 40 to 60 units to treat somebody's neck. It's certainly not less than that. Or if it is, it's probably not doing much. So it's not a great treatment, but it is something if you have some mild bands, sometimes that can help. So Botox is a nonsurgical thing people do. Another thing that I guess I've seen a lot of people do is thread lifting, which I am like the anti thread lifter. And we talked about it on a previous podcast, but I was subject to when the first sort of commercial threads really came to light, which was, I dunno if I can say their name, I guess I can contour thread. So they were a polypropylene thread. It was a barbed suture, but it was a permanent thread, permanent suture. And in order to be able to use these, you had to get special training, which I went and got, and there was all these steps you had to go through. Anyhow, once you got approved, you could put these in. And we were getting phone calls all the time because it had been on Oprah Winfrey. And,

Kirstin (11:31):
Wait, is this the lunchtime facelift?

Dr. Koehler (11:33):
Oh, I don't know what the episode was called, but it was something along those lines. It was basically a really minimally invasive or noninvasive facelift. And so people were calling like, yeah, absolutely. And who wouldn't? Right? I can get the results of a facelift. I don't have to go under the knife, I don't have to go to sleep. I mean, please sign me up. So we were getting lots of phone calls, and then I took the course and I started putting some of these threads in, and I quickly realized after a couple of cases, I'm like, you know what? I'm not buying this. I'm not seeing the results. And at first you sort of go, well, maybe I'm not doing it right, but you start talking to other people and you realize it's not me. This is not a great procedure. And a few years go by, and then ultimately that particular thread got taken off the market. The FDA pulled their approval because of complications.

(12:23):
These were a permanent thread and they were extruding out the face and had you could see these visible marks from when people would smile, you could see these lines where the threads were kind of poking through or peeping through the skin kind of thing. So it really turned out not to be a good thing. So then the threads disappeared and fast forward, I don't know, 10 years, and here we are again, except for now, they're dissolvable threads. So I guess the good news is that eventually it goes away. So if you have some of these other issues with it being visible or whatever, it will ultimately eventually be dissolved. And they changed several things about the threads. But ultimately, if you're a surgeon, you understand what it takes to lift a face, and it's not an easy task.

(13:16):
There's ligaments you have to cut. You to really free up the tissues and to do it in a way that you can reposition them passively and not under tension in order to get a long lasting result. And I can tell you that all that threads are doing is tugging hard on the superficial structures. And yes, you might see a result, but it is going to be for a very short period of time. And I've just seen too many people that have spent a fair bit of money on a procedure that doesn't really work. So again, I'm the anti thread guy. So I don't know, I probably have some thread company calling me now. But anyhow, I always tell my patients, if it's something non-surgical and it's good, we're going to offer it. We offer fillers, we offer Botox. I mean, we do all Dysport, we do all those non-surgical things, and we have a lot of medi spa stuff, so microneedling, radiofrequency, microneedling. We like to offer nonsurgical stuff if we think that it's worthwhile. But the threads, in my opinion, are not worthwhile. And I think if you're going to go to that trouble, you should do a proper procedure. So a facelift or a neck lift is what you need to do. So that's just my advice. But I see a lot of people that have had those threads done in, and I'm sure somebody's happy with a result here or there, but I've definitely seen more problems than I have seen good results.

Kirstin (14:34):
Well, in talking about necks and chins and nonsurgical options, there's an injection that people sometimes ask for that you're also not a fan of. I don't know if we can say the name of it, but.

Dr. Koehler (14:45):
No, we won't say the name of it.

Kirstin (14:46):
Okay, let's talk about that.

Dr. Koehler (14:48):
Well, it's the same reasons. So to me, if you're trying to enhance the jawline, it depends on the circumstances. And I think that I'm just going to say that that filler definitely can have a place. I'm not saying that it can't do what they're claiming, which is to help give definition to the jaw, and it can, but patient selection is key. And then there's so many patients that are just not really good candidates for it, because they may not just need this definition here. They may need something done here to reduce things to give them more jawline, and they might need a chin implant to give them more projection. So yes, if you have just the right candidate, you can use filler to enhance a jawline. But the other thing that I always like to tell people is that, okay, so one syringe of filler is one milliliter of filler and five syringes of filler would fill up one teaspoon.

(15:47):
So when we're talking about correcting jawline here and here, you're not going to be able to do that with one syringe. You're looking at four, six, maybe more syringes, a filler. Now if price was no object for you and you want a resorbable product that will go away, absolutely. It's fine to do it. I guess the reason that I don't promote it is because I'm like for the amount of filler that you need to do, it's a temporary solution. And I guess as a surgeon, we are looking for more longer term solutions. That's not for everybody. So I'm not saying you can't do it. I'm just not as big a fan because I think bang for buck, I just don't know that I'm not impressed.

Kirstin (16:31):
Okay. Are there other surgeries or even nonsurgical procedures that you would do with a neck lift or even post-care that you'd recommend after a neck lift?

Dr. Koehler (16:42):
Well, I mean, we can back up and talk about other procedures that I'd recommend. I mean, there's still a lot of nonsurgical stuff that we recommend, like radiofrequency microneedling to help skin texture and tone realize that that's not tightening skin. I mean, we say nonsurgical skin tightening, and it does improve the skin tone, and so it is going to be tighter. But if you've got laxity, true laxity, it's not going to correct that you need to do that surgically. So microneedling, radiofrequency microneedling, those are great things to add to a procedure. CO2, laser skin resurfacing, we like to do that. I go, those are things that address skin. So we're talking about neck contour and neck shape. Those things don't crack that, but it's like icing on the cake. I mean, it helps the surface, which is great. Renuvion is a technology which is basically, it's a helium plasma, it's like a cautery, and you can use that sometimes to heat the undersurface of the skin to get some better skin contracture.

(17:43):
Again, if it's mild skin tightening that you're looking for, I have found it to be useful. Ultrasound using a vaser or ultrasound assisted liposuction, not to necessarily liposuction, but you can sometimes pass that vaser probe up underneath the skin. And again, it heats the underside of the skin potentially helping with skin contracture. So there are some circumstances where we can use these other modalities to kind of enhance our surgical results, and I think they're good. Again, patient selection is key for all of these things, and it's not like a one size fits all. We don't offer all these things for every patient. Some people don't need it. Some people were like, yeah, you know what, if we add this other modality, maybe we can save you some years before you do a full lower face and neck lift. So sometimes we can do some of those as a sort of a stopgap measure.

Kirstin (18:32):
So if people do some of those things that you recommended, how long will results last before it's time for them to go ahead and move forward with the lower face and neck lift?

Dr. Koehler (18:42):
That's a good question. That's the question that everybody asks, and it's the hardest thing. Sometimes, I've seen some pretty impressive results sometimes with less involved procedures, and they can sometimes last a while. So I always tell people, just take two people that are the same age and maybe let's say in they're both 55 years old and we follow them both until they're 60. Nobody has surgery. I mean, they may age completely differently, and then one person at 60 is still looking fantastic, and the other one may be like, oh, man. Again, all those things that we talked about, genetics, diet, habits, like smoking, all these things, environment, those all impact it. And so we can age differently. So that's why it's hard to answer those questions. But I mean, you got to talk to your doctor about that. And if they're like, look, my experience this procedure, I don't really see very long lasting results. I mean, you got to go with, if you have a doctor that you trust their opinion. I mean, you got to listen to what they have to say.

Kirstin (19:46):
I do have to say that there's definitely people that I graduated high school with that I'm like, dang, girl.

Dr. Koehler (19:52):
Yeah, they look way better than you, huh?

Kirstin (19:54):
No, they look like they graduated with my parents.

Dr. Koehler (19:59):
Oh, okay. Yeah, I'm in so much trouble.

Kirstin (20:03):
Grounded.

Dr. Koehler (20:03):
Grounded.

Kirstin (20:04):
Okay. So if somebody does choose the surgical route, or if you recommend the surgical route, how long are they going to be, do they need to go into hiding for several weeks until they heal? Or is that something where they could go back to work quickly? Or what's the downtime for a neck lift or something like that?

Dr. Koehler (20:20):
Again, depends specifically on each case, but a lot of times isolated neck procedures, people are looking pretty good in a week and pain wise, not bad. So not a lot of downtime. Sometimes, occasionally we'll have people that'll bruise a little bit, and nowadays we've got some things that we do that really help people with that bruising aspect. But overall, I'd say a week for a less involved procedure. And then for doing a full lower face and neck lift, now we're doing this deep plane work and preservation techniques, and I find that people are looking so much better, so much quicker. Whereas before I'd say, oh yeah, four, six weeks, sometimes people are looking pretty good in even just two and three weeks. So varies again from person to person.

Kirstin (21:06):
Do you ever see people in consultation that are concerned about their neck or lower face and neck and you recommend spa treatments first before surgery?

Dr. Koehler (21:16):
If they're like, I'm not interested in surgery. Yeah, I mean, I would say still take care of your skin and do some of these other radio frequency microneedling, that's good for your skin regardless of whether or not you want to tighten and lift and do that kind of thing. So yeah, there's lots, and there's some people that, I mean, I have some great patients that are like Dr. Koehler, I am not interested in a facelift, but I just want to look my best. I'm like, okay, we have things, but just as long as everybody's on the same page and it's like you don't get a $700 non-surgical treatment and expect the result of a much more expensive surgical treatment. These non-surgical things are beneficial and we would recommend them for certain things. But if you're wanting that surgical result, then you got to really be looking at surgery.

(22:01):
And that's sometimes where I feel like that's where the disconnect is. And that's why people, they have this hope with things like thread lifts. They're like, I want a surgical result, but I don't want to go to sleep, and I don't want a recovery, and I think this thread's going to give me that. And I just feel like that's where the disconnect is a little bit. And I think because providers sometimes we're all too willing to say, oh, yeah, this is going to really help you. And not to knock people that aren't surgeons that do those procedures, but sometimes it's not really even a knock, it's that if you only offer fillers, Botox and thread lifts, those are the things that you're going to be recommending. And I think surgeons just look at it a little differently because they're like, okay, well, I offer those things, but then I also offer surgery. And so we're a lot quicker to go, oh, hey, I think you should consider surgery. Whereas people who don't offer surgery, that's usually something they recommend when they're like, okay, there's just not anything else I can do for you. So we're just looking at it from, the same problem, from just two different perspectives is all.

Kirstin (23:04):
Well, I also think that when people come in and say, I want to fix my face, but I don't want surgery. But those reasons are because they don't want pain and they don't want downtime. But really, like you said, a lower face and neck lift or deep plane neck lift or whatever is not really horrible in terms of pain and downtime. So they really need to maybe talk to their friends that have had these procedures done and find out like, no, it's not such a bad thing. Maybe it'd be worth it.

Dr. Koehler (23:32):
Yeah, I mean, obviously there's a lot goes into the decision. There's the recovery, the cost, and there are risks, and the risks of surgery are certainly greater than the risks of putting filler or Botox in or doing a thread lift. So I mean, yeah, there's a lot of things to consider there. But yeah, if you definitely talk to people that do this a lot, that do a lot of facelift and neck lifting. I mean, it is kind of hard sometimes to even recommend some of these non-surgical things to get people where they want to be. It's like there's just no other way you really need to consider this. But again, a little bit of a biased perspective, I guess.

Kirstin (24:12):
Do you have any other recommendations as far as necks and double chins that you want to talk about?

Dr. Koehler (24:20):
Well, I will, yeah, I will share one other, one, another no-no. Again, I have somebody, another company after me, but well, maybe I can use it without the name, but there's like a chemical you could inject in your neck, and it was to melt the fat in the neck. And again, one of these things we hoped it would be really good. And my personal opinion is to stay far away from it. But this is a little bit of a, I've seen this a couple of times, I'll share it with you. So I had a patient that they didn't share with me that they'd had these treatments, this injected into their neck. And again, the whole point is to melt fat in the neck for a double chin. So they've had these injections, it usually takes a series of injections, and I'm sure somebody can show me some great results, and that's fine.

(25:10):
I'm not saying that you can't get any results from it. Just again, when it compare it to surgery, I just don't think it compares. However, this is what I will share with you. So I was doing a surgical procedure for this person's neck, it happened to be a male patient, and they wanted to improve their chin neck contour and all this stuff. So I go in there to do the surgery and I was like, this is concrete. It was so scarred down and so matted down, and if you're not a surgeon, it's really hard to explain. But we understand tissue planes and we know kind of where we're at in the right spot because we know what tissue plane we're in. Well, this just created a matted mess of hard to really discern the tissue planes. And even if you knew of the tissue plane, you're like, it's, it's not dissecting freely.

(26:01):
So anyhow, it made an operation that I would say is a routine operation for me, very challenging and very difficult to even get the kind of result that I wanted. And afterwards, I was like, I was just, so the whole time I just couldn't figure out why this was such a difficult case. And then after the fact I was like, have you had anything done there before? Or liposuction or something?Cuz sometimes we'll see after people have had liposuction, there's a lot of scarring, but this was even different than that. It was worse. And that's when I was told, oh, that I had had a chemical injection.

(26:38):
I was like, oh, man. It was tough. I've had one other time with that. This had been actually quite some time since their last injection. It was, I think, well over a year since their last injection. So it appears that the effects of that can be kind of long lasting. So anyhow, I'm not a fan of that. And sometimes like the old adage, if it sounds too good to be true, maybe it is. And with some of these new technologies, you just got to be careful. You don't necessarily want to be the first one to jump on, and maybe not the last either, but you do need to have, there needs to be enough experience out there that you feel comfortable doing it. And anyhow, not a fan of that one either. So that's my other non favorite, neck procedure. But any other advice that I could give on the neck? I'm just trying to think. I mean, yeah, neck yoga and neck exercises, I don't think that makes a difference. But it wouldn't hurt. It doesn't hurt to do it. If you want to do it, just that's fine.

Kirstin (27:34):
And you briefly mentioned sunscreen, so let's.

Dr. Koehler (27:37):
Oh, protection. Yeah. Want to protect your skin, always. I mean, I'm not very good at it, but that's what I tell people to do.

Kirstin (27:46):
Of all the places, that's where I spray my sunscreen, my neck.

Dr. Koehler (27:49):
Well, I'm not really good about reapplying. That's the problem. I put it on once and then I'm not really good about it anyhow.

Kirstin (27:57):
Okay.

Dr. Koehler (27:58):
Alright. Anything else?

Kirstin (28:00):
Well that's all I got.

Dr. Koehler (28:02):
Alright. Well, yeah, thanks so much. Kirstin.

Kirstin (28:05):
Do you have a burning question for Dr. Koehler or me? You can leave us a voicemail on our podcast website at AlabamatheBeautifulpodcast.com. We'd love to hear from you. Thanks, Dr. Koehler.

Dr. Koehler (28:16):
Thanks Kirstin. Talk to you later.

Announcer (28:18):
Got a question for Dr. Koehler? Leave us a voicemail at AlabamatheBeautifulpodcast.com. Dr. James Koehler is a cosmetic surgeon practicing in Fairhope, Alabama. To learn more about Dr. Koehler and Eastern Shore Cosmetic surgery, go to easternshorecosmeticsurgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, Apple Podcast, Spotify, or wherever you like to listen to podcasts. Follow us on Instagram @EasternShoreCosmeticSurgery. Alabama the Beautiful is a production of The Axis, theaxis.io.