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Noninvasive Neck Rejuvenation

Ioannis P. Glavas and Stephen Bosniak

The neck plays an important role in patients’ self-perception. Neck characteristics and qualities are idealized in the perception of feminine beauty and youth in different cultures. It is widely accepted that a long, thin, slender, “swan’s” neck is a pleasant and graceful characteristic in a woman’s appearance. It is not by chance that jewelry and clothing are created by fashion designers with ambition to attract the eye to the beautiful lines of the female neck. A different set of characteristics is assigned to the male neck. The ideal man’s neck is more often described as a strong, muscular, thick “bull’s” neck, giving an aggressive, dominant quality.

Neck rejuvenation has a balancing and complementary role in the whole approach to a youthful appearance of an individual. The chin and jawline frame the facial characteristics. The elements that influence the appearance of the neck are: the quality and texture of the skin; the amount and firmness of the subcutaneous fat; the platysma muscle strength, thickness, and form; subplatysmal fat; anatomy and prominence of submaxillary glands, thyroid cartilage, and the surrounding bones. The bony structures of the face, neck, and upper chest provide the framework for the attachment of the soft tissues.

It is apparent that the inevitable changes of time upon the tissues can affect the neck to different degrees. The skin loses its turgor and becomes wrinkled and saggy. The platysma muscle may atrophy while hypertrophic medial bands become noticeable, running from the chin down to the clavicles. Submental subcutaneous fat may increase in volume and result in a “double” chin. Jowls may become prominent and sag, further altering the midfacial contours by dragging the facial tissues inferiorly.^1–4 The above multifactorial changes cannot be corrected with any single noninvasive treatment.

Available choices for neck rejuvenation to this point have been largely surgical. Among the surgical techniques are: facialplasty, cervicofacial rhytidectomy, platysmaplasty, corset platysma repair, digastric muscle recontouring, submandibular gland resection, deep plane facelift, and suture suspension. Their goal is to restore youthful facial anatomy by removing redundant tissue or repositioning lax tissue or both.

We have developed a noninvasive, nonsurgical, three-staged approach to neck rejuvenation.⁵ The skin texture and resilience are corrected with superficial chemical peels, privately compounded home care products, nonablative lasers (1320 and 1064 nm), intense pulsed light (IPL), and Thermage (radiofrequency-mediated collagen tightening) therapies (Thermage, Hayward, California). Phosphatidylcholine (Lipostabil, Aventis, France) injections reduce submental fat accumulation. Botox injections relax platysmal banding. The goal of these therapies is to globally rejuvenate the neck by promoting collagen remodeling and regeneration rather than by resection or plication.

Principles of Treatment

Minimally invasive neck rejuvenation can be achieved with a combination of multiple modalities and techniques with different mechanisms of action. The ultimate goal is to combine these actions to get the maximum neck rejuvenating effect with minimum healing and recovery downtime.⁶ Surgical techniques of neck rejuvenation may target specific types of tissues (skin, fat, muscle) depending on their contribution to the aging effect on the neck. But unlike the noninvasive approach, the healing time and recovery period after surgical procedures ranges from weeks to months. The ecchymosis and edema following surgical procedures may restrict the social and professional activities of the patient. For this reason many patients prefer the less invasive rejuvenation modalities even if it means that they will need repeat treatments to obtain the desirable effect and to maintain it.

Sitting directly in front of the patient allows the physician to examine the patient at rest and in animation while building rapport and hearing exactly what the patient’s concerns are. While looking in a mirror, the patient can point to the areas of concern, which will give the patient and the physician an opportunity to establish priorities, discuss the options, and confirm realistic expectations.7,8

Evaluating the Patient

The patient is examined at rest and while speaking, from the front and from each side. The patient is asked to raise the chin and to depress the chin to the chest. The quality, texture, pigmentation, and resilience of the skin are noted. The amount and location of submental fat deposits are noted. The prominence of the submandibular glands is noted. The extent and location of anterior and posterior platysmal bands are also noted. These notations are correlated to the patient’s list of complaints and priorities. In this manner a treatment plan can be suggested and augmented.

Discussing Posttreatment Follow-up and Complications

Even though nonsurgical techniques are much less invasive than surgical techniques are, they are not devoid of possible complications. The risks, possible adverse effects, and alternative treatments should be discussed with the patient. Each of the different therapeutic modalities will have its own set of limitations and possible adverse effects. It is important to explain the usual course following each treatment and when the patient will begin to notice improvement following each treatment. It is also important to emphasize the need for effective maintenance.

Photographic Documentation

Photographic documentation before and after each procedure is essential for patient discussion. It facilitates implementation of future procedures and confirms the results of the recently performed procedure. Patients are photographed before each treatment, immediately after each treatment, 1 to 2 weeks following each treatment, and again after the final result has been achieved. It is most convenient to perform digital flash photographs. These can be downloaded directly into a computer for patient comparison. Although angled soft lighting is better than straight, hard light, it requires special equipment and a more complex setup in the exam/treatment room. The physician or technician taking the photographs should establish a protocol so as to obtain patient poses with the same subject angle, facial expression, magnification, and luminosity. This will make before and after comparisons more accurate and meaningful.

The Setting

Minimally invasive procedures are performed in the office with the patients dressed comfortably in their own clothes while seated in an examination or treatment room. To put the patient further at ease, this should be made a relaxing and nonthreatening environment. Although there is no need for extensive preoperative evaluation and patient preparation, the physician must take all the precautions for infection control and bloodborne pathogens when performing injections or minor procedures. In addition, the room should be adequately equipped with the proper medications and equipment to efficiently address any allergic reactions, syncope episodes, or other emergency conditions related to the performed treatments.

Treatment Options

There is no preset combination of treatments. Each patient is carefully examined and an individualized treatment plan is recommended. Changes in the appearance of the neck may look similar to the patient, but may result from different causes. One example is the “double chin” deformity. The patient sees a double chin regardless of its etiology. From the physician’s standpoint the cause may be excess fat, lax and redundant skin, or a hypertrophic anterior platysmal muscle insertion.

The principle of rejuvenating the neck using noninvasive techniques lies on a simple concept: to rejuvenate each tissue type of the neck independently using tissue specific treatments and to combine the effects of those treatments to achieve a better result. The rationale behind this concept is that the effect of each tissue on the appearance of the neck has a different underlying mechanism. For example, skin gets wrinkled because of degenerating tissue changes, the platysma muscle degenerates and forms hypertrophic bands, and submental fat accumulates. Noninvasive neck treatments fall into one of the following groups based on their ability to:

Alpha hydroxy acid (AHA) peels can be used as an initial treatment. These superficial peels are the least invasive of all skin treatments. They have no downtime. They essentially exfoliate the top layers of the epidermis. The result is a soft and silky texture on the skin. Skin pigmentation can be treated with a series of weekly AHA peels.9 A series of at least five peels, one per week, should be recommended to the patient initially to accelerate early improvement. Patients who can see some result early in the treatment regimen will be encouraged to continue and to complete the program. Although the initial concentration of AHA to be used may depend on the skin quality, it is practical to start with a 70% buffered solution, observe the patient’s response, and advance to higher concentrations during subsequent treatments. After washing the face with a mild cleanser, the skin is degreased with 5% acetone to remove any residual makeup or secretions. Using cotton swab applicators the AHA is applied to the skin of the neck. A timer is set to 10 minutes. After that time (or sooner if the skin becomes erythematous) the AHA is washed from the face with water. Application of a moisturizing serum and sunblock concludes the treatment. The effects of these treatments can be maintained and prolonged by having the patient use home care products daily. The daily use of topical sunscreen and oral antioxidants is essential to prevent further actinic exposure and degeneration. If the patient will not use sunscreen on a daily basis, continued skin care is pointless.

Photorejuvenation of the skin with nonablative light-emitting devices offers impressive results with minimal downtime and minimal patient discomfort (see Chapter 2). These devices emit intense polychromatic noncoherent light in a broad wavelength spectrum of 515 to 1,200 nm.¹⁰ IPL can be used to treat diffuse and discrete pigmented and vascular lesions of the neck skin, including poikiloderma and telangiectasias. This instrumentation can also be used to soften the demarcation between a laser-resurfaced face and an actinically damaged neck.

Related posts:

Teeth and the Perioral Area in Facial Aesthetics Intense Pulsed Light for Full Facial Rejuvenation Injectable Fillers Dental and Bony Architecture in Perioral Rejuvenation Endoscopic Forehead Rejuvenation Neuromodulation and Management of Facial Rhytidosis

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