Surgical interventions require an anesthesia provider, an operating room circulator nurse, a technologist, a surgeon, and potentially an additional surgical assistant, such as an RN first-assist or a physician assistant.

Non-surgical treatments, like injections, can often be performed by a surgeon, a non-surgeon physician, such as a dermatologist, or a non-physician, such as a physician assistant or nurse.

The most important aspect of preparation for any cosmetic procedure is patient counseling and expectation management. Treatment, surgical or otherwise, should not begin until the surgeon or other healthcare provider feels that the patient's goals and expectations are consistent with anticipated outcomes. Additionally, surgical patients should ideally temporarily discontinue anticoagulant therapy and quit smoking, if applicable.

Facial and great auricular nerve function should be evaluated and documented prior to rhytidectomy. Having preoperative photographs of the patient posted in the operating room for reference during the case is also helpful. The patient's jowls and platysmal bands should be marked while the patient is sitting upright, and the nurse performing the surgical scrub should avoid smearing or removing the marks.

Regardless of whether the plan is for general anesthesia or not, injection of local anesthetic or tumescent solution will help to lower the analgesic requirement and aid hemostasis. Intravenous steroids will decrease edema and nausea in the immediate postoperative period, facilitating the patient's discharge to home.[7]

Submentoplasty [3][8][9]

A skin incision is marked in a transverse submental crease, centered and roughly 3 cm in length. A #15 blade is then used to make a single stab incision in the center of the planned incision as well as two more, 1 to 2 mm inferior to the attachment of each ear lobule. A 2 to 3 mm liposuction cannula on a 10 cc control syringe is then inserted through the stab incisions, the submental one first, and subsequently the lateral ones. Care should be taken to face the opening of the cannula away from the dermis so as not to cause postoperative texture irregularities or disrupt the blood supply to the skin.

Dry passes are made with the cannula under the skin to create tunnels prior to applying suction. The assistant should retract the skin away from the surgeon to create appropriate counter tension. The cannula's tip should be just visibly tenting the skin in order to ensure the liposuction remains sufficiently superficial to avoid damaging blood vessels or other important structures. The area of cannula dissection should remain superior to the hyoid and inferior to the border of the mandible, in order to avoid injury to the marginal mandibular nerve and larynx. Maintaining this plane will also facilitate later flap elevation.

The submental incision is then made, allowing dissection to enter the subcutaneous plane. The skin flap is retracted with a double prong skin hook toward the surgeon while the assistant provides counter tension. Facelift scissors, such as Gorney-Freeman or Goldman-Fox scissors, are used to dissect in a subcutaneous plane from the submentum past the level of the hyoid. As the dissection proceeds inferiorly, a facelift retractor can be exchanged for the skin hook. Once the platysma borders are identified, additional lipectomy may be performed in between the muscle bellies if necessary.

A plane is developed along the undersurface of the platysma and carried 1 to 2 cm laterally. Fat on the deep surface may need to be removed; however, excessive fat removal in this area can lead to a cobra neck deformity. The fat that has been removed should be kept in saline in the event it needs to be replaced. If the cervicomental angle is extremely obtuse, the surgeon can dissect the platysma's medial border at the level of the hyoid and divide it transversely. The medial platysmal borders are then approximated with 3 or 4 buried, interrupted sutures.

Neck Lift [9][10]

Attention is now turned to the facial incisions. An abbreviated Blair incision is marked starting anterior to the lobule and proceeding onto the posterior surface of the auricle, and then posteriorly and inferiorly into the hairline. The incision is made with a #15 blade through the dermis and into a subcutaneous plane. Countertension should be applied on the neck, and the flap developed using facelift scissors. Elevation then continues anteriorly to join the submental dissection. The flap is supraplatysmal; therefore, the great auricular nerve and external jugular vein should not be at risk if the correct plane is maintained.

The surgeon places two non-absorbable sutures as buried half mattresses between the lateral border of the platysma and the mastoid periosteum. The vector of pull will be roughly parallel to the posterior border of the helix. The first suture is placed superiorly and the second more inferiorly. After hemostasis is obtained, the flaps are tailored to eliminate redundant skin, and the wounds are closed in layers over a drain, taking care to avoid excessive tension on the suture line.

Antibiotic ointment and a compressive head and neck dressing are applied.

Laser Skin Resurfacing

Settings will vary by device, but it should be remembered that the combined thickness of the epidermis and dermis in the neck is just over 0.25 mm on average, whereas the skin of the cheek is over 1 mm in depth. This, combined with the lower concentration of dermal appendages, means that healing may be slower and less energy should be delivered than when performing facial resurfacing. Fractionated delivery of the laser may be preferable to fully ablative settings, if available, and resurfacing should stop when the papillary dermis is reached, indicated by the presence of pinpoint bleeding and a subtle change in skin color toward a more yellow hue.

Botulinum Toxin Injection

The platysmal bands are visualized with the patient in an upright position, and aliquots of 5 units of botulinum toxin are injected with a fine gauge hypodermic needle (30 or greater) in a vertical line along the medial border of the platysma. Typically, 3 to 6 injection sites are required on each side. The injections will take 1 to 2 weeks to reach their maximum effect and will last for 3 to 4 months. Repeat as necessary.

Other Modalities

The deoxycholic acid injection may be performed roughly every six weeks, but not usually more often than every 4, given the edema that typically follows injections. Cryoablation is also typically performed at roughly one-month intervals until the desired effect is reached; radiofrequency ablation is ideally performed as a single treatment only.

While the most common adverse outcome associated with any cosmetic procedure is dissatisfaction, whether because the effect was insufficient or unexpected, there are several other potential complications that should be avoided if possible. With respect to surgery, hematomas and seromas are common in the early postoperative period, especially in hypertensive patients and patients on anticoagulants. Males are also at an increased risk of hematoma development because of the increased dermal blood flow associated with hair follicles. Over resection of fat in the submental area can result in a so-called "cobra neck" deformity, and excessive tension at closure can pull the ear lobe inferiorly into a "pixie ear" deformity, both of which can be avoided with a more conservative surgical technique.

Permanent or temporary nerve injury can occur as well, particularly to the great auricular nerve, but also to the marginal mandibular branch of the facial nerve. Other standard risks apply as well, such as may occur with any other surgery: pain, bleeding, infection, scarring, alopecia, and need for further surgery.

The best way to avoid these complications is to be familiar with the relevant anatomy, operate meticulously, and counsel the patient thoroughly before surgery to ensure reasonable expectations.  Additionally, the surgeon should have a low threshold for returning to the operating room within a year to perform a "tuck up" procedure to help remove any additional redundant skin that persisted or returned after surgery or to address any remaining platysmal bands, which also frequently recur after neck lifting.[11][12][13]

Non-surgical modalities can result in complications as well, including commonly the complaint that results fell short of expectations. Laser resurfacing may cause burns or scars if the settings are too aggressive; patients should be counseled to stay out of the sun for several months after laser treatments to help prevent any pigmentary abnormalities, either hyperpigmentation or hypopigmentation, that may occur during healing. Hyperpigmentation is most often temporary and is more common than hypopigmentation. Hypopigmentation is less common, but more likely to be persistent and is more difficult to treat.[14]

Injections may produce local reactions, and deoxycholic acid is known for causing significant edema as the adipocytes lyse. Botulinum toxin injection is generally very well tolerated, although if injected too superiorly, it may weaken the lower lip depressors and cause an asymmetric smile. Lastly, in rare cases, cryotherapy may cause paradoxical lipohypertrophy, which will require liposuction to treat.

Because of the wide variety of modalities available for neck rejuvenation, an interprofessional team is an optimal method of providing comprehensive care to the cosmetic patient, ensuring that all pertinent options are presented and discussed appropriately. Experts in all relevant fields should participate in inpatient counseling to determine goals and set reasonable, attainable expectations. Surgeons, dermatologists, nurses, and anesthesia providers all have major roles to play before, during, and after rejuvenation of the aging neck.[15]