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With increasing global trends in aesthetic surgery, the facial plastic surgeon will undoubtedly encounter a variety of patient types including those with more unfavorable underlying anatomy. The "difficult" neck represents a cohort of individuals that exhibit both anatomical and patient-related factors that may limit overall surgical improvement. Anatomical issues that contribute to the difficult neck include excessive fat ("heavy" neck), ptosis of deep structures, obtuse cervicomental angle, and abnormalities of the underlying skeletal framework, such as a low set hyoid and inadequate chin projection. It is important that these factors are recognized and highlighted preoperatively, and that surgery is tailored appropriately to the individual. Although satisfactory results can be achieved, these may be ultimately limited, and it is important that patients understand this. We will present a review of current thinking alongside our own practice in the identification and management of these "difficult neck" patients.