A well-defined neck contour is essential for achieving a balanced, youthful profile in aesthetic surgery. Because neck laxity is one of the earliest and most visible signs of facial aging, neck rejuvenation alone can substantially improve the overall aesthetic profile. Ellenbogen described favorable neck aesthetics as a clearly visible inferior mandibular border from the mentum to the angle, a subhyoid depression, a prominent thyroid cartilage, a visible anterior border of the sternocleidomastoid muscle, and a cervicomental angle (CMA) of 105°–120° [1]. Conventional rhytidectomy remains the gold standard for comprehensively correcting these features of the aging neck; however, patients increasingly prefer less invasive procedures.

Thread lifting is a minimally invasive procedure used to address skin laxity, early jowling, rhytides, or mild fat-pad prolapse [2]. However, it primarily suspends superficial soft tissue and has limited durability and limited ability to reduce volume, particularly in the neck [3,4]. Neck thread lifting as monotherapy is therefore generally limited to younger patients with mild fat prolapse who desire a minimally invasive procedure. Conversely, neck liposuction is appropriate for young patients with minimal skin laxity, moderate platysmal adipose tissue, and minimal platysmal banding. However, it is less effective in patients with little subcutaneous fullness and in older patients with substantial cervical and platysmal laxity, because isolated liposuction may improve the submental contour while exposing platysmal bands and failing to correct skin laxity [5]. Surgical lifts provide more comprehensive correction but are more invasive and costly than other available options.

From an anatomical perspective, three distinct planes must be considered in neck contouring. The superficial plane lies between the skin and platysma; the intermediate plane, beneath the platysma, contains subplatysmal fat, the anterior belly of the digastric muscles, and the submandibular glands; and the deep plane lies below the deep cervical fascia [6]. To reduce the risk of injury to adjacent vital structures, our intervention was performed primarily in the superficial plane.

This study presents a combined technique using syringe liposuction and counter-directional thread traction to overcome the limitations of either method when used alone. During liposuction of the submental and submandibular areas, undermining of the superficial layer reduces subcutaneous volume and enables effective thread advancement and firm anchoring between the skin and platysma muscle. The threads are strategically placed: laterally inserted threads pull the sagging neck skin superolaterally, whereas a midline thread creates a sling effect by pulling the skin medially and establishing a new CMA. This dual-vector thread lift therefore mimics the mechanics of a formal neck lift or rhytidectomy, improving submandibular definition and the CMA.

To date, evidence regarding the efficacy of combined thread lifting and liposuction for neck contouring remains limited. In this study, we evaluated the outcomes of this combined technique using objective parameters, including CMA change, liposuction volume analysis, and ultrasound imaging, to address the limited objective evidence in previous reports of thread lifting.

The mean patient age was 40.0±12.4 years, and the cohort included 12 men and 39 women. Longitudinal changes in the CMA after the procedure, analyzed using LMMs to account for concurrent adjunctive procedures and follow-up attrition, are summarized in Table 2. Overall, the CMA improved significantly over time (F(4, 57.85)=22.54, P<0.001). Comparisons with the baseline angle of 125.91° confirmed significant angular reductions at postoperative day 1 (110.97°, P<0.001), 3 months (115.74°, P=0.001), and 12 months (114.33°, P=0.003). Although the 1-month postoperative data did not show statistical significance, they still demonstrated a trend toward angular reduction (119.33°, P=0.084). These findings indicate that aesthetic improvement occurred immediately after the procedure, likely because of physical traction, and that a reduction of approximately 10° was maintained through 12 months, supporting the durability of the procedure.

Liposuction volume analysis showed a mean injected tumescent volume of 70.4±7.1 mL, a mean aspirated volume of 42.3±9.7 mL, and a mean sedimented volume of 16.6±5.3 mL. The aspiration-to-tumescent, sedimented fat-to-tumescent, and sedimented fat-to-aspiration volume ratios were 60.3%, 23.8%, and 40.1%, respectively (Table 3). At the 3-month evaluation, the mean GAIS score was 2.39 (n=19), corresponding to improvement on the scale. All patients reported enhanced submandibular border definition and an improved neck angle after the operation. Preoperative and postoperative ultrasonography confirmed secure anchoring of the thread barbs to the platysma muscle (Fig. 2). This engagement was attributed to the reduction in subcutaneous tissue thickness achieved by the procedure, which was also confirmed by postoperative ultrasound findings.

No major complications were observed; only minor complications occurred. One patient developed a small hematoma that resolved with conservative management. Two patients experienced entry-site scarring, which was successfully treated with triamcinolone injection and a neodymium-doped yttrium aluminum garnet laser for hyperpigmentation (Table 4). All patients showed improved submandibular border definition and a more favorable neck contour at 3 and 12 months postoperatively.

In our procedure, liposuction provided several key advantages. In patients with mild-to-moderate fat accumulation in the submental area, liposuction is necessary for submental contouring because the submental triangle strongly influences the final contour and is particularly affected by adiposity [7]. Beyond volumetric reduction, liposuction undermines tissue, thereby facilitating thread advancement. We believe that the tumescent technique is the most appropriate and safest approach for this procedure. Saline expands the fat tissue, epinephrine causes vasoconstriction and decreases bleeding, and lidocaine provides local anesthesia [8]. These effects persist after liposuction and during thread insertion.

According to our data, approximately 40% of the aspirate volume consisted of fat tissue, corresponding to 24% of the total infiltrated tumescent volume. This relationship enables reverse calculation of the required tumescent fluid volume based on the estimated amount of fat to be removed. In this study, the infiltrated tumescent volume was maintained between 60 and 80 mL across all patients to ensure consistency. Although the volume of aspirated submental fat correlated positively with the patient’s preoperative fat accumulation, sufficient tumescent fluid was infiltrated for hydrodissection and safety even in cases of minimal fat accumulation, in which dissection is inherently more challenging.

After liposuction, the dissected space allows the threads to be placed in the proper layer and engage the platysma muscle because subcutaneous tissue thickness has been reduced. In addition, when new adhesion forms between the skin and platysma, skin contraction and repositioning may further reduce the CMA, representing another indirect benefit of liposuction. Thread lifting can elevate superficial tissues; however, it has limited capacity for volume reduction and is usually associated with early recurrence, particularly in the neck. Bae et al. [9] suggested that thread lifting combined with liposuction in facial rejuvenation is more sustainable and effective than thread lifting alone. We believe that thread lifting combined with liposuction may have a similar effect in the neck. By integrating the two approaches, we observed sustained improvement in the CMA, with an approximately 10° reduction at 3 months and low complication rates, suggesting that this combination may provide more balanced correction than liposuction or thread lifting alone.

Fat aspiration is beneficial; however, a conservative approach to aspiration volume is advisable in older patients with poor skin quality and substantial laxity. This approach may help prevent complications such as excessive skin sagging or platysmal band exposure. Anatomically, the procedure is considered relatively safe because, although platysma muscle penetration is possible, vital neurovascular structures usually remain in the deeper planes of the neck [10,11]. In a few cases involving excess fat accumulation, subplatysmal liposuction was performed through bilateral submandibular entry sites without complications. Dayan et al. [12] reported that chin augmentation with an implant alone decreased the CMA. In our patients with microgenia, chin augmentation was performed using aspirated autologous fat from the submental area.

Another distinctive component of this study was the use of counter-directional traction forces. The two opposing vectors, superolateral and central traction, replicate the mechanical effects achieved in surgical platysmaplasty as described by Feldman [13]. Superolateral traction is anchored to the platysma-auricular ligament and provides lateral suspension of the lower neck, replicating the mechanical effect of lateral platysmaplasty. This lateral platysma pull helps improve mandibular border definition. The central vector advances the platysma muscle, mimics the effect of midline plication, and acts as a suspension suture to accentuate the CMA [14]. In our experience, thread placement is most effective when the entry point is created 1 cm anterior to the anticipated final CMA. This initial design functions similarly to the main cable of a suspension bridge: although initially lax, thread tension increases as tissue contraction occurs, gradually increasing lifting force. Initially, dimpling or mild overcorrection may be observed at the midline. However, a line shift typically occurs within 2–3 days, producing a natural contour aligned with the desired cervicomental line. This dual-vector design creates muscular hammock support, defines the jawline, and accentuates the CMA.

Because conventional thread lifting is generally performed without direct visualization, confirming accurate engagement of the thread barbs within the target tissue is often challenging. To address this limitation, ultrasonography was used to objectively verify that the threads were properly placed just superficial to the platysma. Technically, after liposuction, the threads were advanced through the newly created plane without tissue resistance, enabling smooth and accurate placement. As a critical precaution to prevent the threads from becoming palpable or visible postoperatively, aggressive removal of superficial fat should be avoided. A sufficient layer of superficial subcutaneous fat must be preserved to provide adequate soft-tissue coverage over the threads. Postoperative care for this combined procedure largely follows standard protocols for neck liposuction. However, specific precautions are required because threads are placed concurrently. If patients experience discomfort associated with postoperative tissue induration or firmness, very gentle ultrasound massage therapy may be administered to relieve symptoms.

Absorbable sutures degrade after several months. However, the combination of thread lifting and liposuction may provide a synergistic effect that facilitates more effective and durable skin repositioning. The procedures promote adhesion between the skin and platysma, which may sustain the lifting effect after thread degradation, consistent with the findings reported by Guerrero-Santos [15]. In addition, objective ultrasonographic validation is rarely reported in thread-lift studies, and its inclusion here strengthens the evidence supporting this combined method.

The aesthetic results, reflected by a mean GAIS score of 2.39, are consistent with improvement reported in other minimally invasive rejuvenation procedures [3,8,16]. Serial images show profile changes from the preoperative to postoperative periods (Figs. 3, 4). Clear improvement was observed in submandibular border definition and resolution of excess submental fullness. However, during the first month, the results may be partially obscured by ongoing tissue changes after liposuction or incomplete resolution of the initial wound-healing phase. Patients typically experience hardness, edema, and ongoing fat resorption in the treated area; consequently, they may not perceive subtle improvements because residual volume has not fully diminished and the CMA may remain obtuse. By 3 months postoperatively, the soft tissue matures and softens. At this point, the CMA becomes clearly improved, and patients begin to recover sensation in the procedure area.

Nevertheless, this study has several limitations. The procedure primarily addresses the superficial plane between the skin and platysma and does not correct deeper structures, such as submandibular gland ptosis or most deep fat compartments [17]. In cases of excessive deep fat accumulation, deep fat liposuction was occasionally performed through the submandibular entry point; however, we anticipate that this approach is less effective than traditional formal lipectomy. Furthermore, this method may yield unsatisfactory results in patients with severe skin sagging or laxity and cannot fully correct prominent platysmal bands. Patients with more advanced cervical aging may therefore still require a formal surgical neck lift for optimal outcomes. The inability to correct complex structural or bony deficiencies is another important limitation. These deficiencies include a low-positioned hyoid bone, a small or retracted chin, shortened submental length after mandibular or chin setback procedures, and severe skin or superficial musculoaponeurotic system laxity [18]. Younger patients with good skin elasticity who had skin sagging after mandibular or chin setback surgery or bone-contouring surgery showed favorable results with this method. Conversely, aesthetic improvement was generally less pronounced in male patients, possibly because of thicker skin, increased intraoperative bleeding, and less robust skin contraction [19]. Therefore, this procedure appears most effective for older patients with mild-to-moderate skin laxity accompanied by some degree of fat accumulation and for younger patients with good elasticity who present with skin sagging and residual fat after bone-contouring surgery. These factors underscore the importance of careful patient selection and thorough preoperative counseling.

A potential limitation of this study is the high proportion of patients who underwent concurrent adjunctive aesthetic procedures, which could act as confounding variables. To control for these effects, the type of adjunctive procedure was incorporated as a fixed effect in the LMMs. A time-by-procedure interaction term was also included as a sensitivity analysis to determine whether the longitudinal trajectory of CMA improvement differed between the procedure-only subgroup and patients who received combined treatments. The analysis showed that the main effect of adjunctive procedures was not statistically significant (P=0.105). The interaction between time and adjunctive procedures was also not significant (P=0.078). This nonsignificant interaction suggests that the trajectory of CMA improvement was statistically similar across the cohort, regardless of whether adjunctive procedures were performed or which type was used. These findings suggest that adjunctive treatments did not substantially distort the outcomes and that the primary combined technique contributed to the observed aesthetic improvements in the lower face and neck.

A major limitation of this study is the steep attrition rate, with only approximately 20% of the initial cohort remaining at 12-month follow-up. As is typical for minimally invasive aesthetic procedures, satisfied patients often decline long-term clinic visits. Although LMMs were used to statistically compensate for missing data and minimize bias, the small long-term sample size limits the strength of our conclusions. Future studies with larger cohorts and longer follow-up are warranted to further validate the durability of this technique and refine selection criteria. Comparative studies against isolated liposuction, thread lifting, or surgical neck lifting would also provide valuable insight into the relative benefits and limitations of each modality.

This study suggests that combining counter-directional thread traction lifting with syringe liposuction provides a more comprehensive approach to neck contouring by addressing the inherent limitations of isolated procedures. The synergistic effect appears to arise from three mechanisms: excess fat reduction, secure thread anchoring to the platysma, and effective repositioning of the skin overlying the platysma. By addressing both soft-tissue repositioning and volumetric reduction, this combined method may overcome limitations associated with either technique alone.

Objective validation with ultrasonography confirmed secure thread engagement with the platysma layer, supporting the anatomical basis of this approach. Complication rates were low, and no major adverse events occurred. We recommend using the tumescent technique during liposuction to achieve safe and effective hydrodissection and tissue undermining. Careful patient selection is essential for optimal results. Conservative fat extraction in older patients appeared important for avoiding postoperative sagging.