Chin Up: What To Do with a Sagging Neck?

Lipo, lasers, lifts, and injections are just a few of the options to confront sagging wattles. Alexandra Marshall sticks her neck out.

A Starring Roll

When injectables took over the world in the early aughts, having facial wrinkles became more of a choice than an inevitability. But at the same time, armies of women of a certain age started to look like the Real Housewives of Beverly Hills, and I began to believe that there was something honest and rock ’n’ roll about being able to move my face. I actually like my crow’s-feet, and I can live with the lines between my eyebrows. But—and there is always a but—no one warned me about my neck. As noble as a few frown lines may look in post-Botox America, there is no air of refusenik coolness to a wattle.

Every woman I know who has reached her early 40s and woken up with a falling chin or a wavering jawline agrees. (No wonder the late Nora Ephron’s 2006 book I Feel Bad About My Neck was a best-seller.) “This neck thing just makes me feel old,” my friend Gillian, a 43-year-old interior designer in Los Angeles, told me while wrapping her ever present cotton scarf tightly around her throat. I know exactly what she means. I’m 42 and have become conscious of an area that I’ve named “the drop zone”: the increasingly declining curve between my neck and jaw, which used to be a taut right angle. Tick down a list of women generally considered to have aged gracefully: Audrey Hepburn in her UNICEF years, Lauren Hutton, Kristin Scott Thomas. What are three things they have in common? A believably lined face, a sharp jawline, and a swanlike neck. But contenders like Diane Keaton and Candice Bergen, on the other hand, wear an awful lot of markedly high collars; Ephron was an avowed fan of the turtleneck, perhaps attempting to dispense with the unwanted area altogether. Alas, this is a strategy with seasonal limitations and highly impractical sartorial consequences.

To make things worse, the aging neck is a particularly difficult area to treat. “The problem is threefold,” said Michael Kane, a Manhattan plastic surgeon with a booming practice in necklifts. “You’ve got sagging muscles and bulging fat. And the skin in that area gets crepe-ier faster than anywhere else on your body because it’s the thinnest, except for your eyelids.” In addition to this daunting trifecta, something starts happening to the neck as we age: A thin ropey muscle called the platysma splits into a V-like formation of two cords that protrude more and more when they contract. If you’re in your 40s or older, and this has somehow escaped your notice, look in the mirror, say “eee,” and watch in horror what happens. Trying to fix all of that with potions and lotions is like waging a two-front war on a sheet of thin ice.

So what are our options? Once upon a time, before repeated viewings of Extreme Makeover and our collective obsession with digital self-portraiture turned us into amateur aging detectives, women my age didn’t go under the knife to de-sag. Those days are over. Kane sees the necklift as ideal for women in their early to mid-40s who aren’t quite ready to go for a full facelift. “It’s a way to kick the can down the road for about seven to ten years,” he said, describing a procedure that sews together and wraps sagging muscles crosswise to the jaw in order to restore that all-important right angle. Sutures are smaller, there is less pulling, and recovery time is much shorter than with a full facelift. There is also the famous trampoline lift, performed under local anesthesia, which raises drooping skin and muscles by tying them up with filaments inserted under the skin.

Neck to neck, clockwise, from left: Audrey Hepburn, 1988; Diane Keaton, 2012; Lauren Hutton, 2008; Kristin Scott Thomas, 2012.

But what if you’re not sagging so much as blowing up? Double chins, those unwelcome destroyers of august female dignity, also come with advancing years as we naturally gain weight—and our looser skin, weaker muscles, and free-falling fat do their thing. My friend Ann, a 45-year-old publicist in New York, told me that her chin made her look “like a giant baby.” Norman Leaf, a prominent Beverly Hills plastic surgeon, is a fan of treating puffy necks and double chins with SmartLipo, which uses lasers to melt fat and has the welcome side effect of tightening the skin. Ann, who underwent the procedure, noted that “even after I got pregnant and gained tons of weight, it held.” For those without the Cabbage Patch Kid look but some loose fat around the neck, conventional lipo­suction, too, can wipe out the drop zone. None other than Susan Sarandon, that paragon of graceful maturity, eschewer of Botox and facelifts, recently admitted to having it done.

Plastic surgeon David Rosenberg, one of Manhattan’s acknowledged kings of the natural-looking lift, was one of the few doctors I spoke to who felt surgery was premature during one’s early 40s. “I’d be much more likely to send you to a good dermatologist for a few more years,” he told me. This may sound like good news, but I’ve always been suspicious of dermatological fixes, which are expensive when compared with the results—and usually require the kind of maintenance I don’t have the time or the patience to undertake. Besides, drooping muscles are a big part of the problem here, so what can surface work really do?

It turns out dermatologists do have some interesting alternatives. London-based Jean-Louis Sebagh is a proponent of preventively injecting necks with Botox. “If you start when you’re around 30, you’ll keep the neck and jowl muscles from sagging at all, and you can put off a facelift until you’re 50,” he said. “I’ve done it to myself for 15 years.” Botox can also soften the dreaded V-shaped platysma cords, which are, after all, just contracting muscles. But, Sebagh warns, “if you ignore your neck, as so many women do, and then suddenly pay attention when you’re 48, Botox is not going to help you.” For double chins, a biopharmaceutical company called Kythera is close to releasing an injectable that uses a synthesized form of human bile to dissolve the middle-age dewlap.

I’m not a fan of shooting foreign substances into my body on a regular basis, so these two wouldn’t be for me anyway. Nor would the fillers that are said to tighten the jawline in order to pull up some of the neck sag. But if something is harvested from my own body, I’m all for it. While I was in Los Angeles—that Wild West of self-improvement technology—I paid a visit to Nathan Newman, the Beverly Hills dermatologist who created the Stem Cell Lift. The treatment is, essentially, grafting—injecting fat from, say, your belly into your face to give it extra volume—with the sci-fi twist of adding a dose of your own stem cells into the syringe. Human fat already contains adult stem cells, but, Newman claimed, the extra amount (which he separates from the fat via centrifuge and then adds into what he’s injecting) makes the skin glow more, enhances collagen growth for dewy plumpness, and produces longer-lasting results than a traditional fat transfer. He said that boosting temples, cheeks, and the hollows below the mouth could lift mini-jowls and tighten up the drop zone. Not surprisingly, the use of stem cells has caused some controversy in the world of aesthetic medicine. Last year, the American Society of Plastic Surgeons and the American Society for Aesthetic Plastic Surgery put out a joint statement against the marketing of stem cell procedures until more studies can be done. In any case, I wasn’t looking to change the contours of my entire face—just to take care of the area right below it. Moving right along.

When it came to the neck, the plastic surgeons I spoke to were almost uniformly skeptical of some of the trendier devices like Thermage, Ulthera, and Titan, which deliver, respectively, radio frequency, ultrasound, and infrared laser to goose the layers below the epidermis—an area in which collagen and elastin production slows down as we get older. The problem with all of these, the surgeons told me, is that the devices don’t generally deliver enough energy to have a substantial effect. That is why New York–based Macrene Alexiades-Armenakas, M.D., and a handful of dermatologists around the country are enthusiastic about Evolastin, a radio-frequency device that delivers heat via small injections directly into the deep dermis. (A typical treatment can include as many as 1,500 shots via pulses from a 10-needle cartridge; local anesthesia is used—or the pain would be unbearable.) “Imagine that aging is a curve where you get worse over time,” Alexiades-Armenakas said. The boost of collagen and elastin produced by Evolastin “shifts the curve, so you’re farther behind on it,” she explained. It’s like setting the clock back about five years. “The aging process will resume, but you’ll always look younger.” Alexiades-­Armenakas claimed that the results, which take approximately one month to become apparent and continue to ramp up over a year, are equivalent to about one-third of a facelift.

That, coincidentally, is about as much of a lift as I was looking for, so I made an appointment with Edward Ross, a dermatologist in San Diego. Once I was numbed, the whole thing took just 40 minutes, and the only real pain was from the anesthesia shots. But the recovery process! Evolastin’s parent company, Syneron, claims that patients can resume normal activity in 24 hours. I would say that’s true only if your normal activity consists of wearing a bag over your head. The procedure, with its hundreds of shots (and, consequently, hundreds of sub­dermal 69-degree-Celsius zingers), is, as Ross noted in one of our ­follow-up consultations, “traumatic.” The day after, my face had swollen to twice its size. Tiny red dots appeared all over my cheeks, jaw, and chin. Though they were mostly injection irritations, which disappeared in a few days, I wasn’t prepared for them: Looking like a teenager in the midst of an acne breakout was hardly the fountain-of-youth effect I was hoping for. For a week I felt like Eric Stoltz in the movie Mask, and I refused to even leave the house. Ross assured me all of this was my body’s natural healing process. I assured him it was not fun.

Now, three months later, the swelling is a dim, rather comic memory, and the drop zone is slowly starting to shrink. “There is no instant gratification with this procedure, which makes it kind of hard to market,” Ross said. “But it works.” The crumpled, grandmotherly texture of the skin on my neck feels thicker, heartier, and tighter. The procedure hasn’t made my cords disappear nor completely redrawn my jawline, though the only one who could do that would be a plastic surgeon—one who will, in all likelihood, be getting a call from me in a few years. As Norman Leaf told me, “The only people who say they want to age gracefully and mean it are 18.”

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Photos: Neck; Torkil Gudnason/Trunk Archive; Hepburn, Keaton, Hutton: Corbis; Thomas: Getty Images