How Do I Make My Neck Smoother and What Do the Shadows Come From?

Facial shadows can be good AND bad. If we watch cartoons, artists typically place as few shadows on a “beautiful” female face as possible. Think of Cinderella. Meanwhile, the jawlines, cheekbones, and abdomens of superheroes are shadowed like crazy. As a plastic surgeon, I often try to create facial shadows where none exist, for example over the buccal space or under the jawline. Still, other facial shadows detract from facial beauty. In other words, it is my job to eliminate suboptimal facial shadows. This is very apparent in lower blepharoplasty surgery, facelift and neck lift. Also, let us not forget that we typically use fillers and fat grafting to eliminate nasolabial folds (“smile lines”) and melolabial folds (“marionette lines”) which are, in essence, facial shadows. I feel that addressing anatomic cause of these facial shadows is more effective than simply masking them with fillers. Although injectables like fillers and fat grafting can enhance surgical results, there is an endpoint that should be respected. In this video, I focus on the bad shadows. Particularly, those that occur in the lower face and neck.

I was inspired to create this video by a patient who presented to my clinic last week. She is young woman who had successful buccal fat pad removal surgery at another practice. Although I cannot seem to find any fault with her cosmetic result, she is unhappy with the depression that occurred under her cheekbone, and the fullness that seems to have become more noticeable in front of that space. This is the first time I have seen or heard any such complaint by patient as it was my understanding that creation of that contour or convexity is the desired outcome of buccal fat pad removal surgery. However, her disappointment exposed a whole new paradigm for facial beautification and rejuvenation in my practice. It was the first time that I saw perceived discord of facial harmony as a result of buccal fat pad removal surgery. Although I thought she looked great, her perception is valid, and I think I understand exactly why.

I never saw the patient before buccal fat pad removal, as she sought intervention elsewhere. However, the patient has heavy perioral mounds. Perioral mounds are convexities that occur on the outside corner of the lips and tend to turn downward. This can be thought as the starting point of the marionette line and can confer an unhappy appearance as it causes the corners of the lips to turn downward somewhat. Or at least to appear that way. In retrospect, it is possible to imagine that this was the presenting concern of the patient to another surgeon. This was the problem area that she wished to have addressed. Maybe there was a lapse in communication between the woman and her surgeon, but buccal fat pad removal alone did not address the perioral mounds- it made them more apparent, by creating a depression behind. Not that the mounds became bigger, but to the patient, the perioral mounds were relatively more prominent as a result of debulking the buccal fat pads. Again her result looked very good to me, but her presenting concern may not have been adequately addressed.

I see this with other treatments for the face. For example, many patients choose to reduce facial width by injecting a neurotoxin like Botox to the masseters. When you do this, the muscle weakens and becomes smaller. As a result, the face narrows posteriorly and you are somewhat weakening the jawline angle. This is typically overlooked as patients are satisfied with a relatively safe, reversible, and non-invasive nature of this treatment. However, in some patients, and those who often request Botox for their masseter muscles, the soft tissue in front of the masseter muscle, in the anterior one half of the face, may become relatively more prominent. Because structures like jowls may be hidden by fullness of the masseter muscle, correction of masseter hypertrophy exposes a different anatomic problem area for some patients. In our practice, we are seeing this more and more, and we typically treat this so-called “masseter atrophy deformity” (M. A. D.) with filler along the jawline to recapitulate mandibular continuity. In the aging face, many additional shadows exist. We touched on some of the structures in this video. However, I do not discuss other structures like the platysma muscle, the mandible itself, and subcutaneous fat in detail. In many cases, the shadows that we see are normal anatomic structures. While they typically do not detract from beauty, many patients are understandably bothered by a neck and jawline that are not smooth. Many times, the shadows are formed by nonsurgical and surgical procedures like Kybella, liposuction, and radiofrequency assisted lipolysis with liposuction. In other cases, weight loss alone is enough to expose many of these structures. Still, and a minority of cases, some abnormal contours can be explained by disease processes and may not be aesthetic in nature.

Ultimately, many, if not all, of the shadows can be corrected both surgically and nonsurgically. In the aging face, facelift is my go-to procedure to eliminate many of the shadows, while creating new ones that are more aesthetic in nature. This video simply scratches the surface of a much more important topic that I will expound upon in future videos. The bottom line is this: the face is not an exception to these general principles in aesthetic surgery:

1) it is critical to hear the patient’s specific concerns and treat them accordingly, and

2) respect and protect facial harmony when facial features are modified