Key points

Introduction

The growth and success of minimally invasive aesthetic procedures has spawned a dramatic increase in development of technologies and treatments aimed at addressing the growing cosmetic concerns of an aging population. The exemplary results and minimal morbidity afforded by botulinum toxin type A (BoNTA) and soft-tissue filler treatments has caused the patient population to become increasingly adverse to the downtime and perceived inconvenience associated with surgical procedures. Likewise, the aesthetic provider must adapt to the changing demand of patients and accommodate their needs. Often, the fervor for the latest and greatest minimally invasive alternatives may outpace the promised results, and it is of utmost importance that the aesthetic provider is aware of the appropriate treatment so as to achieve an excellent cosmetic result.

The aging process is often associated with untoward effects on the neckline, including accumulation of fat, redundancy of skin, laxity in the platysma, and ptosis of the underlying anatomy, resulting in the appearance of a heavy neck or “turkey gobbler” appearance caused by an increasingly obtuse cervicomental angle. Neck-lifting techniques incorporating skin excision, lipectomy, platsyma-muscle alteration, lifting procedures, and chin alterations traditionally were used to tighten the neck and overcome skin laxity. However, with the advent of new devices and techniques aimed at reducing morbidity and recovery time, a variety of new options with which to combat the aging neck are available to the aesthetic provider.

Although the future of these minimally invasive options is promising, it remains imperative to use careful patient selection and to understand the limitations and capabilities associated with each procedure when selecting the appropriate treatment plan.

Introduction

The growth and success of minimally invasive aesthetic procedures has spawned a dramatic increase in development of technologies and treatments aimed at addressing the growing cosmetic concerns of an aging population. The exemplary results and minimal morbidity afforded by botulinum toxin type A (BoNTA) and soft-tissue filler treatments has caused the patient population to become increasingly adverse to the downtime and perceived inconvenience associated with surgical procedures. Likewise, the aesthetic provider must adapt to the changing demand of patients and accommodate their needs. Often, the fervor for the latest and greatest minimally invasive alternatives may outpace the promised results, and it is of utmost importance that the aesthetic provider is aware of the appropriate treatment so as to achieve an excellent cosmetic result.

The aging process is often associated with untoward effects on the neckline, including accumulation of fat, redundancy of skin, laxity in the platysma, and ptosis of the underlying anatomy, resulting in the appearance of a heavy neck or “turkey gobbler” appearance caused by an increasingly obtuse cervicomental angle. Neck-lifting techniques incorporating skin excision, lipectomy, platsyma-muscle alteration, lifting procedures, and chin alterations traditionally were used to tighten the neck and overcome skin laxity. However, with the advent of new devices and techniques aimed at reducing morbidity and recovery time, a variety of new options with which to combat the aging neck are available to the aesthetic provider.

Although the future of these minimally invasive options is promising, it remains imperative to use careful patient selection and to understand the limitations and capabilities associated with each procedure when selecting the appropriate treatment plan.

Treatment goals

In contrast to the varying invasive surgical techniques, nonsurgical approaches are often more focused on the superficial dermis and supporting tissues rather than deeper underlying neck structures. The cervicomental angle is the landmark most associated with improving the appearance of the neck, and is formed by a line tangent to the submentum from the menton to the subcervicale and a line tangent to the neck intersecting at the subcervicale. Ideally this angle is 126° for males and 121° for females and is particularly influenced by the level of the hyoid bone, which helps to define the jawline. A more obtuse cervicomental angle if often associated with ptosis of adipose tissue in the anterior neck. With nonsurgical treatments, one is primarily addressing the dermal structures of the neck and is aiming at modest improvements in cervicomental angle.

Another goal of minimally invasive treatments of the aging neck should be addressing sun-damaged areas. Chronic actinic changes may appear dry, leathery, and mottled with discolorations. Nonsurgical treatments aimed at reducing the appearance of creping or cobblestone-appearing skin and homogenizing the skin tone can enhance the aesthetic outcome.

In the near future, it is likely that Nd:YAG laser and lipolytic agents may also be able to address excess adipose tissue located in the anterior neck, and help correct the appearance of a heavy neck that would previously have been treated by either direct excision or suction lipectomy.

Algorithm for determining invasive versus less invasive

Improvement in the appearance of the neck, whether surgical or nonsurgical, should attempt to reestablish a well-defined jawline and a more acute cervicomental angle. However, it is critical to listen to patients and understand their wishes, desires, and their commitment level to undergoing a treatment. For patients with significant submental neck laxity and prominent submental fat, nonsurgical methods may fall short of the patients’ expectations, especially if they imagine themselves with a tight neckline and a sharp cervicomental angle. In these situations, it may be best to recommend a surgical modality or none at all. Other patents may be more concerned with the appearance of their jowls or chin position, and this may be best addressed with fillers, surgical implants, and/or face lifting.

Nothing can be more discouraging to a practice than a reputation of not meeting patients’ expectations. It is very important to understand the concerns of the patient and to ensure that realistic expectations are established. However, surgery is not an option for many patients who cannot afford the downtime or expense of surgery, or who are adamantly opposed to a surgical procedure. For those with mild laxity, minimal submental fat, and thicker skin, nonsurgical methods seem to offer reliable and predictive integral improvement in the appearance of the neck. In addition, those with crepey, dyschromic, and actinically affected skin will likely need a dermally directed treatment regardless of the underlying neck anatomy. Often this can be offered in an office-based setting, using an ablative or nonablative energy-based device or chemical peel. Successful outcomes are directly dependent on the ability of the aesthetic provider to assess underlying neck anatomy and the desire of the patient to deliver an acceptable result.

Patient selection

When discussing a minimally invasive procedure, it is important to understand the psyche and goals of patients, so that the best option or combination of options to meet their cosmetic aspirations is chosen. If a patient uses his or her hands to pull back the neck skin to give a tightened-appearing cervicomental angle, then likely a nonsurgical treatment will not meet the patient’s demands. Likewise, if a patient requests a neck lift and expects to have a change in skin texture and tone, he or she will also likely be disappointed. At the core of successful patient selection is listening to the wants of the patient and selecting whether a surgical approach aimed at eliminating skin redundancy, a minimally invasive approach aimed at modest improvements in laxity and enhancement of texture and tone, or a combination of surgical and nonsurgical treatments is appropriate. A successful outcome, whether surgical or nonsurgical, is achieved by translating the outcomes expected with each procedure so as to set realistic patient expectations.