Signs of photodamage on the chest, such as xerosis, rhytids, dyschromia, telangiectasias, atrophy, textural irregularities, and laxity, accumulate rapidly. As interest has grown in facial and neck rejuvenation, the abrupt transition to a photodamaged decolletage has become more obvious and disconcerting to patients. Pigmentary alterations and fine textural changes can be addressed using intense pulsed light, non-ablative fractional lasers, ablative fractional lasers, Q-switched and picosecond lasers, and chemical peels. Biostimulatory fillers, hyaluronic acid fillers, neuromodulators, and microfocused ultrasound are used for moderate-to-severe rhytids.
Key points
- •
When rejuvenating the chest, a personalized and multimodal plan based on the physical examination findings is necessary for optimal outcomes.
- •
Intense pulsed light, microfocused ultrasound, and injectable biostimulatory fillers can be combined on the same day to treat all aspects of the aging chest.
- •
Intense pulsed light and non-ablative fractional lasers, when performed on the same day, act synergistically to improve pigmentary alterations and fine textural changes on the chest.
- •
Q-switched and picosecond lasers can be used for dark, discrete lesions in combination with intense pulsed light and/or non-ablative fractional lasers to improve heavily pigmented chest.
Introduction
The chest is routinely exposed to extrinsic aging factors such as ultraviolet exposure and thus, like the face and neck, ages rapidly. Clinically, this is characterized by xerosis, rhytids, dyschromia, telangiectasias, atrophy, textural irregularities, and laxity. On a histologic and molecular level, aging skin is characterized by epidermal atrophy, flattening of the rete ridges, decreased dermal thickness, downregulation of collagen and elastin synthesis, degradation of the preexisting collagen and elastin, as well as lipoatrophy [ ].
As interest in facial and neck rejuvenation grows, the abrupt transition to a photodamaged decolletage has become more obvious and disconcerting to patients. Thus, rejuvenation of the chest is now a common inquiry in the office as patients seek a seamless transition between the face, neck, and chest.
Options for chest rejuvenation have expanded and include injectable fillers, neuromodulators, chemical peels, and laser, light, and energy devices ( Fig. 1 ). Given the myriad of changes seen in photodamaged skin, a personalized and multimodal plan based on the physical examination findings of an individual patient is necessary for optimal outcomes ( Table 1 ). In this article, the ever-expanding treatment options for chest rejuvenation and the way they can be combined are discussed.
| Treatment | Application | Advantages/Disadvantages |
|---|---|---|
| Biostimulators (PLLA/CaHA) | Moderate-to-severe rhytids | Long duration Requires a series of treatments |
| Hyaluronic acid fillers | Moderate-to-severe rhytids | Immediate correction Short duration with re-treatment needed every 6–8 mo |
| Neuromodulators | Mild-to-severe rhytids | Short duration with re-treatment needed every 3–4 mo |
| Intense pulsed light | Lentigines/hyperpigmentation Erythema/telangiectasis Textural changes/fine lines | Little to no downtime Requires a series of treatments |
| Non-ablative fractional lasers | Lentigines/hyperpigmentation (1927 nm) Textural changes/fine lines (1550, 1440 nm) | Requires a series of treatments |
| Ablative fractional lasers | Lentigines/hyperpigmentation Erythema/telangiectasis Textural changes/fine lines | Reserved for fitzpatrick skin type (FST) I–III High risk of scarring/dyspigmentation Prolonged downtime |
| Q-switched lasers | Lentigines/hyperpigmentation | Preferred for spot treatment |
| Picosecond lasers | Lentigines/hyperpigmentation Textural changes/fine lines | Requires a series of treatments Safe in all skin types |
| Microfocused ultrasound | Moderate-to-severe rhytids Laxity | No downtime Safe in all skin types |
| Superficial chemical peels | Lentigines/hyperpigmentation Textural changes/fine lines | Inexpensive Requires a series of treatments |
Dermal fillers
Biostimulatory fillers
Biostimulators, including calcium hydroxylapatite (CaHA) and poly- l -lactic acid (PLLA), represent a distinct type of dermal filler that acts through dermal regeneration via the production of collagen and elastin. Given these properties, they are commonly used off-label in the decolletage for the improvement of skin quality, wrinkles, and skin laxity.
In a pilot study, hyperdilute CaHA at dilutions of 1:2 for normal skin, 1:4 for thin skin, or 1:6 for atrophic skin was administered as subdermal injections into the neck and decolletage of 20 subjects over two treatment sessions 4 months apart. Both the subjects and investigators were satisfied, and objective improvement in skin elasticity, pliability, and dermal thickness was noted on cutometry and ultrasound [ ]. In a prospective study, one treatment of hyperdilute CaHA (1:2) led to a significant improvement in the validated Merz Decolletage dynamic and rest scales at week 6 through day 360 [ ]. In two global consensus papers, experts recommend one syringe of CaHA at a 1:2 to 1:4 dilution based on patient’s skin thickness using cannula and retrograde injections in the subdermal plane with three to five entrance points [ , ]. Follow-up at 6 to 9 months is recommended to determine if repeated treatment is needed [ ].
PLLA has also been readily used in the rejuvenation of the chest. In early studies, PLLA was injected into the neck and decolletage of 36 patients using a 10-cc dilution. Subdermal depot injections were performed more than one to four treatment sessions with clinical improvement lasting up to 18 months [ ]. A later prospective trial of 25 patients revealed improvement in the validated Fabi-Bolton five-point chest wrinkle scale after intradermal injections of PLLA at a 9-cc dilution [ ]. In a retrospective review of 28 patients, a 16-cc dilution of PLLA was injected into the chest over an average of 2.8 treatment sessions with a similar improvement on the Fabi-Bolton scale [ ]. Despite the varied dilutions described in the early literature, experts recommend more dilute suspensions (ie, 16 cc) to avoid adverse events such as nodules. A 25-gauge, 1.5-inch cannula or needle can be used to deposit retrograde linear threads of product in the subdermal plane. Total product administered to each area depends on the patient’s severity but is commonly between half to one vial. Three to four treatments spaced at least 4 weeks apart are generally recommended [ ].
Hyaluronic acid fillers
Hyaluronic acid (HA) fillers with low cohesivity can be used for the correction of deep chest wrinkles and furrows via serial puncture or retrograde linear threads in the dermis using a 30- or 32-gauge needle. The use of nonanimal, stabilized HA (NASHA) fillers diluted with 3 mL of bacteriostatic saline and 22.5 mg/mL monophasic HA filler (Belotero Balance; Merz, Frankfurt, Germany) diluted with 0.2 to 0.5 mL of 1% lidocaine without epinephrine have been described in the literature [ , ].
HA fillers outside of the United States have also been used for chest rhytids. A 12 mg/mL NASHA filler (Restylane Vital Light; Galderma, Uppsala, Sweden) is available in parts of Europe and Asia. The product can be injected into the mid or deep dermis with a needle or an autoinjector for microdroplet deposition [ ]. A recent prospective, single-center study in Germany investigated the use of a 17.5 mg/mL Vycross HA filler for correction of chest wrinkles [ ]. Up to 3 mL of filler with a touch up at 1 month was administered in boluses using a 30-gauge needle or linear threads using a 25-gauge cannula with superb results [ ].
Although HA fillers have demonstrated efficacy in correcting chest lines, they often require greater volumes with shorter duration of action (6 to 8 months) when compared with their biostimulatory counterparts.
Neuromodulators
The platysma is a large muscle with its lower portion inserting in a fan-like fashion, most commonly onto the second or third rib, but often beyond [ ]. Contraction of inferior portion of the platysma exerts traction forces to the overlying skin contributing to horizontal and vertical rhytids in the decolletage [ ].
In an early case series of five patients, 30 units of onabotulinum toxin A (Botox; Allergan Inc, Irvine, CA) were injected along two lines: one parallel to the intercostal spaces at the most caudal contraction pattern and the second in a V shape starting presternally. Improvement in chest rhytid severity was noted in all patients [ ]. A subsequent international consensus regarding abobotulinum toxin A (Dysport; Medicis, Scottsdale, AZ) recommended a V-shaped injection pattern with either 16 or 12 injection points of 7.5 or 10 units per injection point, respectively, for treatment of chest rhytides [ ].
Laser, light, and energy devices
Laser, light, and energy devices represent another large category of tools available for rejuvenation of the aging chest that can target superficial photodamage to deep rhytids and laxity. Of note, although these devices are regularly used on the face, the chest is associated with longer recovery times and increased complication rates given its thinner skin, atrophic subcutaneous layer, and paucity of pilosebaceous units. Parameters must be adjusted appropriately and certain devices avoided all together to avoid scarring and dyspigmentation.
Intense pulsed light
Intense pulsed light (IPL) has been used for decades to correct photodamage of the decolletage given its unique ability to target the vascularity, pigment, and fine textural changes of poikiloderma.
In an early retrospective study of 135 patients treated with IPL for poikiloderma, the neck and chest, a significant reduction (75%–100%) was noted in 82% of the patients after an average of three treatments [ ]. Long-term follow-up at 4 years revealed persistent improvement in skin texture, telangiectasis, and pigmentation in 83%, 82%, and 79% of subjects, respectively [ ]. These results have since been recapitulated [ , ]. In a retrospective chart review of 54 patients, a series of IPL treatments was comparable to a single thulium fiber laser treatment in rejuvenating the chest [ ].
Photodynamic therapy (PDT) has been combined with IPL for treatment of both medical and esthetic concerns of the chest. In a prospective, split chest pilot study involving 20 female participants with moderate-to-severe photodamage of the chest found superior improvement in the side treated with PDT and IPL compared with the side treated with PDT only at the 24-week follow-up [ ].
IPL represents an enticing treatment option as the procedure is quick and associated with minimal-to-no downtime. It should be noted that side effects including dyspigmentation and scarring can be seen, and IPL should be used with extreme caution in those with Fitzpatrick skin types IV or greater. If used at all, a higher cutoff filter, lower energies, longer pulse durations, and multiple sequential pulsing with 30 millisecond delay or greater should be used [ ].
Non-ablative fractional lasers
Non-ablative fractional lasers (NAFLs) have risen in popularity due to decreased downtime, improved comfort, and fewer adverse events when compared with their ablative counterparts. NAFLs remain a mainstay in chest rejuvenation as they can improve dyschromia, as well as textural irregularities and fine lines.
The 1550-nm fractioned erbium glass laser can be used for fine lines and textural irregularities given its deeper penetration, although it is limited in its correction of moderate-to-deep lines [ ]. A significant improvement has been noted in non-facial areas, including the chest, after three consecutive treatments with the 1550-nm erbium glass laser at 3- to 4-week intervals [ ].
The 1927-nm thulium fractionated laser (TFL) has a large water absorption coefficient which leads to more shallow or limited penetration and thus ideal for correction of epidermal pigmentation including lentigines, pigmented seborrheic keratoses, and even actinic keratoses [ , ]. The TFL is often combined with the 1550-nm fractioned erbium glass laser during a single treatment for improvement in both the deeper and more superficial layers of the skin [ ].
NAFLs have been readily adapted for use on non-facial areas since their inception. Improvement in texture, rhytids, dyschromia, and actinic keratoses can still be appreciated, although the energy and density are decreased to avoid complications [ , ]. The 1440-nm and 1927-nm non-ablative fractional diode laser can be used on the chest in all skin types with fewer safety concerns given their lower density and energy, although a series of treatments is required for comparable results [ ].
Ablative fractional lasers
Ablative technologies, including fractional lasers, are not commonly used on the chest given the predisposition for poor wound healing and thus scarring [ ]. If used, extremely conservative settings (ie, ≤10 mJ and 5%–10% density) are used in Fitzpatrick skin types I–II. Even so, prolonged healing and erythema lasting between 10 and 14 days should be expected [ ].
In an early pilot study involving 10 patients with poikiloderma, fractionated carbon dioxide (CO 2 ) laser was performed on the neck and the chest. One to three treatments at 6- to 8-week intervals were performed until significant improvement was noted (mean of 1.4 treatments). At the 2-month follow-up, improvement was noted in skin laxity, pigmentation, erythema/telangiectasis, and texture with global cosmetic improvement noted in 66.7% of participants [ ]. Fractionally ablative CO 2 and erbium: yttrium–scandium–gallium–garnet lasers have since been used on the chest in Fitzpatrick skin types I–III with improvement in rhytids, skin quality, elastosis, and hyperpigmentation [ ]. Prolonged erythema has been described in the literature [ , ].
Q-switched and picosecond lasers
Q-switched lasers, including the ruby (694 nm), alexandrite (755 nm), and neodymium-doped (Nd):yttrium aluminum garnet (YAG) (frequency-doubled 532 nm and 1064 nm) lasers, use nanosecond pulse durations to target melanosomes and eradicate pigmented lesions on the aging chest, including solar lentigines and pigmented seborrheic keratoses [ , ]. Q-switched (QS) lasers work best for stubborn, isolated lesions as oppose to large, non-discrete, reticulate pigmentation in which field therapy is preferred [ ]. Care has to be taken in darker skin types, especially when using the ruby, alexandrite, and frequency-doubled 532-nm Nd:YAG lasers due to a higher risk of dyspigmentation and scarring.
In more recent time, picosecond (PS) lasers have been used in rejuvenation harnessing their photomechanical and photothermal effects on tissue. A specialized diffractive lens array creates high-fluence apices surrounded by low-fluence areas allowing for good clinical effects while optimizing safety [ ]. In one prospective trial, 20 patients with moderate-to-severe decolletage photodamage received up to four treatments of 755-nm PS alexandrite laser with diffractive lens array [ ]. Laser energy was applied over the entire treatment area at a fixed spot size of 6 mm, with a fluence of 0.71 J/cm 2 and 10 Hz until a minimum of 3500 pulses were delivered or a clinical endpoint of moderate erythema was achieved (typically two to four passes) [ ]. Discrete pigmentary lesions or rhytids were treated with focused passes to clinical endpoint of mild greying/frosting [ ]. At the 1-month follow-up, clinical improvement was noted in dyspigmentation, texture, keratoses, and rhytids. At 3 months, continued improvement was noted in all aforementioned categories except rhytids, which did not reach statistical significance [ ]. The ability to improve pigmentary lesions as well as texture in a safe manner using “pico-toning” has since been recapitulated [ ].
Microfocused ultrasound
Microfocused ultrasound (MFU) creates areas of coagulation at varying depths up to 4.5 mm depending on the device and transducer resulting in neocollagenesis in the dermis and fascia while sparing the overlying papillary dermis and epidermis. It is used on facial and non-facial areas to correct rhytids and laxity with minimal-to-no downtime. The effects bypass the epidermis making the procedure safe in all skin types.
In an early pilot study, 24 subjects with moderate-to-severe rhytids of the chest received MFU with visualization with a pass at 4.5- and 3.0-mm depths (120 lines each) [ ]. At the 6-month follow-up, 86% of subjects were improved by physician evaluation scores and women with breast size less than 400 mL achieved an average of 1.4 cm elevation of the nipples [ ]. A subsequent clinical trial involving 125 patients with deep-to-very deep chest lines received a pass at the 4.5-, 3.0- and 1.5-mm depths (120, 120, and 40 lines, respectively) with improvement in 69.9% and 66.4% of participants at the 3- and 6-month follow-ups, respectively [ ].
Chemical peels
Superficial chemical peels, including glycolic acid (30%–70%), salicylic acid, Jessner’s solution, resorcinol (20%–50%), and TCA (10%–30%), penetrate the epidermis and have been used safely in rejuvenation of the chest [ ]. Medium-to-deep chemical peels that penetrate to the level of the papillary dermis and beyond are avoided on the chest given poor wound healing and increased risk of dyspigmentation and scarring.
A 70% glycolic acid immediately augmented with 40% TCA and subsequently neutralized with 10% sodium bicarbonate solution has been described in non-facial areas including the neck, chest, arms, hands, and back with improvement in texture, wrinkles, and pigmentary abnormalities [ ]. A series of 20% to 30% salicylic acid peels in combination with a topical 4% hydroquinone/2% glycolic acid topical product also improved wrinkles, texture, and pigmentary changes on the chest [ ].
Choosing and combining therapies for chest rejuvenation
When formulating a plan to rejuvenate a chest, a thorough examination must be performed and therapies should be tailored to each individual patient (see Fig. 1 ; see Table 1 ).
If pigmentary problems predominate, IPL, non-ablative NAFL, chemical peels, QS, and PS lasers should be considered first. IPL is favored in patients who also have a component of erythema and/or telangiectasias. In more severe cases, a series of treatments is required. In those with more moderate-to-severe lentigines, NAFL such as the 1927-nm TFL can be used with significant improvement after just one treatment. A series of chemical peels is favored for those with mild pigmentary changes. QS and PS lasers are preferred for treatment of few discrete lesions.
In those with textural changes and fine lines, IPL and superficial chemical peels can help in addition to improving pigmentary alterations. PS lasers is a good option for darker skin types and can also improve both fine lines and pigment. A series of treatments is recommended for the aforementioned modalities. When moderate-to-severe textural changes predominate, NAFL laser such as the 1550-nm fractionated erbium laser is often used. In those with Fitzpatrick skin types I–II, an AFL using conservative settings (low fluence and low density) is also an option.
If deeper rhytides predominate, injectable biostimulators such as PLLA or CaHA and MFU provide long-lasting improvement. HA fillers and neuromodulators provide immediate correction, although have a shorter duration of action.
In reality, patients present to clinic with multiple, if not all, features of photoaging including erythema/telangiectasias, pigmentary alterations including hyper- and hypopigmented areas, textural changes/fine lines, and deep rhytids. No single treatment can address all these factors, and thus, a multimodal approach tailored to each individual-based is critical. Thoughtful consideration should be put into combining modalities to ensure synergy for maximal efficacy and convenience to the patient ( Table 2 ) [ ].
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
