NAL Neck Artificial Ligament Lifting: Neck Rejuvenation with Polytetrafuotoethylene (PTFE) Bands


  • Alessandro Gennai Private Practice Via Delle Lame 98, Bologna, Italy
  • Mattia Colli Private Practice Via Podgora 7, Milan, Italy
  • Andrè Salval Private Practice Via Podgora 7, Milan, Italy



Cervicoplasty, Neck, Rejuvenation, Aging, Mandible, Platysma Muscle


Background: The current surgical method allows a short recovery and minimally invasive technique with polytetrafluotoethylene (PTFE) bands application, minimal skin excision for a fallen platysma muscle and skin laxity in facelift surgery; the clinical advantage of this method is a short recovery and an anatomic less invasive dissection, ideal for also younger patients who want more and more short healing times. Methods: Retrospective analysis of a 294 cases series of patients seeking platysma and skin laxity increase of neck-face region were included in the study. All of them were primary neck-face lift performed with PTFE bands of dual mesh that are customized for suture to the platysma and anchored to the mastoid, creating a neck artificial ligament (NAL) that is buried into the muscle and tightened, without modifying the superficial musculoaponeurotic system and platysma. Result: Data collection on surgery time, implant dimension selection, and postoperative complications were included. The most frequent complications were rare and include 5 case of superficial epidermolysis (healed within 21 days) and 1 case of mild band infection (treated with antibiotics). The surgical results are still stable over time, like those of a normal facelift after 6 months. Conclusion: minimally invasive NAL application avoids a large dissection and deep modifications of the superficial musculoaponeurotic system and platysma getting a strong upward tension that lasts over time with stable results.


Donofrio LM. Fat distribution: a morphologic study of the aging face. Dermatol Surg 2000;26:1107-1112. 1-00270.x

Little JW. Volumetric perceptions in midfacial aging with altered pri- orities for rejuvenation. Plast Reconstr Surg 2000;105:252-266. 00045

Ellenbogen R, Youn A, Yamini D, Svehlak S. The volumetric face lift. Aesth Surg J 2004;24:514-522.

Pessa JE, Zadoo VP, Yuan C, et al. Concertina effect and facial aging: nonlinear aspects of youthfulness and skel- etal. 00042

Remodeling, and why, perhaps, infants have jowls. Plast Reconstr Surg 1999;103:635-644. 00042

Lambros V. Observations on periorbital and midface aging. Plast Reconstr Surg 2007;120:1367-1376; discus- sion 1377. 56.c3

Yaar M, Gilchrest BA. Skin aging: postulated mechanisms and consequent changes in structure and function. Clin Geriatr Med 2001;17:617-630. 6

Stuzin JM. Restoring facial shape in face lifting: the role of skeletal support in facial analysis and midface soft tissue repositioning. Plast Reconstr Surg 2007;119:362- 376; discussion 377-378. 60.25

Coleman SR, Grover R. The anatomy of the aging face: volume loss and changes in 3- dimensional topography. Aesthetic Plast Surg 2006;26:S4-S9.

Raskin E, LaTrenta GS. Why do we age in our cheeks? Aesthetic Surg J 2007;27:19-28.

Fitzgerald R, Graivier MH, Kane M Lorenc P, Vleggaar D, Werschler P, Kenkel JM (2010) Update on facial aging. Aesthet Surg J 30:11S– 24S.

El Domyati M, Attia S, Saleh F, et al. Intrinsic aging vs. photoaging: a comparative histopathological, immuno- histochemical, and ultrastructural study of skin. Exp Der- matol 2002;11:398-405. 0625.2002.110502.x

Henderson J, O’Neill T (2010) Direct anterior neck skin excision for cervicomental laxity. Aesthetic Plast Surg 34:299–305.

Parsa FD, Castel N, Parsa NN (2016) A modified, direct neck lift technique: the cervical wave-plasty. Arch Plast Surg 43:181–188.

Ullmann Y, Levy Y (2004) Superextended facelift: our experi- ence with 3,580 patients. Ann Plast Surg 52(1):8–14. 913.3e

Matarasso A, Matarasso SL, Brandt FS, Bellman B (1999) Botulinum A exotoxin for the management of platysma bands. Plast Reconstr Surg 103(2):645–652. 00043

Cronin TD, Biggs TM (1971) The T–Z-plasty for the male ‘‘turkey gobbler’’ neck. Plast Reconstr Surg 47(6):534–538. 00002

Coleman SR (1997) Facial recontouring with lipostructure. Clin Plast Surg 24:347–367. 5

Structural fat grafts: the ideal fillers? Coleman SR.Clin Plast Surg. 2001 Jan;28(1):111-9. 9

Tiryaki KT, Aksungur E, Grotting JC (2016) Micro-shuttle lifting of the neck: a percutaneous loop suspension method using a novel doubleended needle. Aesthet Surg J 36:629–638.

Triple suture for neck contouring: 14 years of experience. Citarella ER, Condé-Green A, Sinder R.Aesthet Surg J. 2010 MayJun;30(3):311-9.

Atiyeh BS, Dibo SA, Costagliola M, Hayek SN (2010) Barbed sutures Blunch time^ lifting: evidence-based efficacy. J Cosmet Dermatol 9:132–141. 2165.2010.00495.x

Paul MD (2008) Barbed sutures for aesthetic facial plastic surgery: indications and techniques. Clin Plast Surg 35:451–461.

Fabi SG (2015) Noninvasive skin tightening: focus on new ultra-sound techniques. Clin Cosmet Investig Dermatol 8:47–52.

Fabi SG, Goldman MP, Mills DC, Werschler WP, Green JB, Kaufman J, Weiss RA, Hornfeldt CS (2016) Combining microfocused ultrasound with botulinum toxin and temporary and semipermanent dermal fillers: safety and current use. Dermatol Surg 42:S168–S176. 1

Botulinum toxin: a review of applications for the head and neck. Seidman LM, Brooks JK, Bashirelahi N.Gen Dent. 2019 MarApr;67(2):55-58.

Global Aesthetics Consensus: Botulinum Toxin Type A—Evidence-Based Review, Emerging Concepts, and Consensus Recommendations for Aesthetic Use, Including Updates on Complications. Sundaram H, Signorini M, Liew S, Trindade de Almeida AR, Wu Y, Vieira Braz A, Fagien S, Goodman GJ, Monheit G, Raspaldo H; Global Aesthetics Consensus Group.Plast Reconstr Surg. 2016 Mar;137(3):518e-529e. 09.23

Botulinum Toxin for Neck Rejuvenation: Assessing Efficacy and Redefining Patient Selection. Jabbour SF, Kechichian EG, Awaida CJ, Tomb RR, Nasr MW.Plast Reconstr Surg. 2017 Jul;140(1):9e-17e.

Gonzalez R (2009) Composite platysmaplasty and closed percutaneous platysma Myotomy: a simple way to treat deformities of the neck caused by aging. Aesthet Surg J 29:344–354.

Pontes R (1991) Extended dissection of the mental area in face-lift operations. Ann Plast Surg 27:439–456. 00007

Simplifield closed plastysmotomy. Gonzalez R.Aesthet Surg J. 2010 May-Jun;30(3):489-90..

Closed platysmotomy: a new procedure to treat platysma bands. Gonzalez R.Aesthetic Plast Surg. 2013 Jun;37(3):636-7. Epub 2013 Apr 3.

Narasimhan K, Ramanadham S, O’Reilly E (2016) Secondary neck lift and the importance of midline platysmaplasty: review of 101 cases. Plast Reconstr Surg 137:667e–675e.

Sklar LR, El Tal AK, Kerwin LY. Use of transcutaneous ultrasound for lipolysis and skin tightening: a review. Aesthetic Plast Surg. 2014;38(2): 429–441.

Alam M, White LE, Martin N, Witherspoon J, Yoo S, West DP. Ultra- sound tightening of facial and neck skin: a rater-blinded prospective cohort study. J Am Acad Dermatol. 2010;62:262–269.

Gliklich RE, White WM, Slayton MH, Barthe PG, Makin IR. Clinical pilot study of intense ultrasound therapy to deep dermal facial skin and subcutaneous tissues. Arch Facial Plast Surg. 2007;9:88–95.

Matarasso A (2014) Managing the components of the aging neck: form liposuction to submentalplasty, to neck lift. Clin Plast Surg 41: 85–98.

Auersvald A, Auersvald LA, Oscar Uebel C (2017) Subplatysmal necklift: a retrospective analysis of 504 patients. Aesthet Surg J 37: 1– 11.

Lateral SMASectomy Chaudhry O, Levine S.Clin Plast Surg. 2019 Oct;46(4):523-532. doi: 10.1016/j.cps.2019.06.003. Epub 2019 Jul 30.

Neck Rejuvenation: Anatomy and Technique Charafeddine AH, Couto RA, Zins JE.Clin Plast Surg. 2019 Oct;46(4):573586. Epub 2019 Aug 2.

The Pinch Rhytidectomy: A Safe, Effective, "Low SMAS" Variation on the Theme. Rosenfield LK.Aesthet Surg J. 2014 Aug;34(6):825-40. Epub 2014 Aug 1.

Conrad K, Chapnik JS, Reifen E (1993) E-PTFE (Gore-Tex) suspension cervical facial rhytidectomy. Arch Otolaryngol Head Neck Surg 119:694–698. 0114023

Prabhat A, Dyer WK (2003) Improving surgery on the aging neck with an adjustable expanded polytetrafluoroethylene cervical sling. Arch Facial Plast Surg 5:491–501.

Use of polytetrafluoroethylene (Gore-Tex EPTFE Soft Tissue Patch) for suspension of former facial paralysis and as reconstructive tissue. 0098013

Use of polytetrafluoroethylene (Gore-Tex EPTFE Soft Tissue Patch) for suspension of former facial paralysis and as reconstructive tissue. Levet Y, Jost G.Ann Otolaryngol Chir Cervicofac. 1987;104(1):65-9.

Zarem HA (1984) Standards of photography. Plast Reconstr Surg 74: 137-146. 00028

Persichetti P, Simone P, Langella M, Marangi GF, Carusi C (2007) Digital photography in plastic surgery: how to achieve reasonable standardization outside a photographic studio. Aesthetic Plast Surg 31: 194-200.

Becker DG, Tardy MEJ (1999) Standardized photography in facial plastic surgery: pearls and pitfalls. Facial Plast Surg 15: 93-99.

Sanniec KJ, Velazco CS, Macias LH, Zuhlke TA, Casey WJ, Leighton WD, Mahabir RC, Rebecca AM (2016) Adherence to photographic standards: a review of ASPS and ASAPS member surgeons’ websites. J Aesthet Reconstr Surg 2:1–7.

Polytetrafluoroethylene as a spacer graft for the correction of lower eyelid retraction. Lee YJ, Khwarg SI.Korean J Ophthalmol. 2005 Dec;19(4):247-51.

Experience with expanded polytetrafluoroethylene (ePTFE Gore-Tex) surgical membrane for coronary artery grafting: does ePTFE surgical membrane predispose to postoperative mediastinitis? Kajiwara H, Hamada T, Ichikawa Y, Ishi M, Yamazaki I.Artif Organs. 2004 Sep;28(9):840-5. 1594.2004.07298.x

De Benito J, Righesso R (2007) Surgical treatment of cervical region associated with polytetrafluoroethylene platysmal suspension sutures. Rev Soc Bras Cir Plast 22: 202–208.

Kim JM, Jang YJ, Kwon BS, Arakaki M, Hong SJ (2010) Lower face-lift with expanded polytetrafluoroethylene superficial musculoaponeurotic system extension graft (Bandlift Implant). J Craniofac Surg 21:1928–1931.

Daniel R. Butz, MD; Kiranjeet K. Gill, MD; Jasmine Randle; Natalie Kampf; and Julius W. Few, MD. Facial Aesthetic Surgery: The Safe Use of Oral Sedation in an Office-Based Facility. Aesthetic Surgery Journal2016, Vol 36(2) 127–131.

Auersvald A, Auersvald LA, Oscar Uebel C (2017) Subplatysmal necklift: a retrospective analysis of 504 patients. Aesthet Surg J 37: 1– 11.