Since the beginning of time, a beautiful neck and well defined jaw are highly sought after features that signify youth, health, femininity and beauty. In the 14th Century BC, Queen Nefertiti was known for her striking beauty and sculpted neck lines. Today, women are frequently requesting a refined jaw line similar to Angelina Jolie or Jennifer Lopez. With the modern advancements in aesthetic medicine, there are many ways to achieve a more sculpted jaw line and smooth feminine neck without going under the knife.

Ageing and anatomy: The aesthetic anatomy of the neck can be divided into several layers, from superficial to deep, starting with the skin, subcutaneous tissue, superficial muscular-facial layer and deep subplatysmal structures. Senescent changes of the mature neck include accumulation of fat, laxity of muscular support, and the cumulative effects of photodamage and gravity. These contribute to the loss of definition of the cervicomental angle, submental fullness, sagging of the jowls, inelasticity and redundancy of the skin, along with platysmal band formation. As a result of these developments, the lower facial third may appear fuller, which can diminish the ‘heart-shaped’ facial shape that is so widely associated with a youthful appearance. The minimally invasive, nonexcisional interventions includes laser, light, radio frequency, high-intensity focused ultrasound (HIFU) energy-based therapy ,injectable soft tissue fillers, neuromodulators, and ablative and nonablative technologies for skin rejuvenation, as well as suture-based suspensory techniques, all used alone or in combinations can help in rejuvenation of this area.

Important limitations to treatment include the anterior location of the thyroid and parathyroid glands, which must be shielded from deeply penetrating wavelengths. There is increased scarring risk on neck and chest as compared to face, thus necessitating greater care and lower fluences in this region.

Understanding a patient’s concern and cosmetic goals is key to successful treatment. The treating physician should be aware of their general health, diet and lifestyle factors, medications used, history of treatments, skin care routines etc. The patients should be asked the questions on how much the problem bothers them and whether or not they would consider cosmetic surgery, which can help to establish what type of treatments to offer the patient. All non-surgical skin tightening and rejuvenation treatments require the patient to be able to commit to a consistent skincare regime in order to enhance and maintain results. Patients should know why they should wear a daily SPF and why their smoking habit might be impending their results. Once we have the basic education in place the rest of the dialogue is easy. Next, a decision should be made on what treatment to offer, this is often dependent on the patient’s budget. Injectable treatments in combination with other procedures can help patients achieve dramatic non-surgical results.

Baseline and follow-up photography from both sides is exceedingly important, as the degree of improvement in neck laxity is often best appreciated by side views. It is recommended that the baseline and first set of follow-up photographs be reviewed with the patient if the level of efficacy is in question. Patients are cautioned that in the vast majority of cases, multiple treatment sessions are required to achieve significant tightening, depending on the technology used.

Nefertiti Lift: Jaw sculpting and neck lift using injectables are described in consumer media often as the ‘Nefertiti Lift’. For many people, the combination of injectable filler and botox can be a perfect nonsurgical solution to achieve a refined, elegant and defined neck and jawline.

Injectable fillers work extremely well for enhancing the jaw line. By adding volume, we can build upon the existing bone structure and create a stronger, more defined line. The injections are placed along the jaw bone in the areas where enhancement is desired. Side effects may include mild bruising and swelling for a few days. It is recommended to avoid anything that has a blood thinning effect on the body for at least one week prior to injections. It is also helpful to take arnica and/or bromelain tablets for a few days prior to treatment as well as a few days following (or as directed).

After the filler is injected into the desired areas, we can further improve overall appearance, sculpting the jaw and neckline with botulinum toxin injections. This procedure is done by injecting botulinum toxin around the jawline and down the neck into the platysma muscle, which is responsible for the downward pull along the jaw. By relaxing this muscle, the muscles on the upper face become stronger and naturally lift the face upwards. The end result is a youthful, tighter, more contoured appearance. These injections are more delicate than upper face botulinum toxin treatments and require an experienced operator who has excellent knowledge of the muscles of these regions, their functions, the antagonist actions exercised on other muscles, particularly in terms of the complex equilibrium of the mouth. An excessive dose, an inappropriate injection point, or a centering mistake can all easily be responsible for undesirable side effects. However, the results obtained, often with lower doses than in the superior part of the face, can be highly satisfactory.  A series of 3 to 5 botulinum toxin  injections are placed  1-2 cm apart on a horizontal line under the mandible posterior to the hypothetical line were the nasolabial fold meets the mandible. If present, injection of each platysmal band every 2 cm with 2 to 4 injection points per band (injection of platysmal band will be done by holding the band between 2 fingers and injecting intramuscularly, doing so ensures that you are only injecting the platysmal band; you don’t want to inject the deeper muscles in the neck as they could affect swallowing) A total of 20 to 30 units of botulinum toxin type A is used. Follow up will be done at 15 days for retouching or for post op pictures if no retouching is needed. If retouching is needed post injection pictures will be taken 10 days post retouching. Botulinum toxin can be injected every 4 to 6 months in order to maintain the results. It is not recommended to repeat the injections any sooner because of the risk for antibody formation and muscle-atrophy. Very dilute hyaluronic acid gels in the subdermal space, as well as PRP (patelet rich plasma) and other stem cell injections, have also reported to provide reasonable rejuvenation of the neck.

Chromaphore-based pathologies of the neck is common, given its sun-exposed location on the head and neck region. Topical therapies including bleaching agents, peeling agents, sunscreens , chemical peels, mesotherapy, chromophore-based lasers and light-based sources (532-nm wavelength Potassium titanyl phosphate (KTP) lasers, 694.5 nm Q-switched Ruby, and the 755 long-pulsed or Q-switched Alexandrite lasers, Pulsed dye lasers in the 585-nm wavelength and IPL ) can be used in different combinations. Generally, for neck rejuvenation in skin types I, II, and III, with dyschromia, cutoff filters in the 515-nm to 580-nm range have been very successful. For skin types 4 and 5, long wavelength cutoff filters in the 590-nm to 640-nm ranges, lower energies, and longer pulse configurations have allowed the treatment of darker discoloration in patients with more advanced  Fitzpatrick skin type. It is important that the IPL settings are gentle moderate in fluence, as IPL may induce a permanent hypopigmentation or discoloration of the skin.  Fractional nonablative and ablative lasers, and ablative fractional radiofrequency devices has also provided an opportunity to improve dyschromia and photoaging, as well as fine lines and texture of the neck.

Complications of the management of melanin and dyschromia of the neck include scars from overzealous laser and light-based settings, hypopigmentation from aggressive settings that result in a complete or near-complete clearance of melanocytes, as well as demarcation from treated and untreated areas.

Vascular or hemoglobin-based neck rejuvenation: The vascular proliferation derived from photoaging responds very nicely to the intense pulsed light, deep dermal and subdermal, proliferative vascular lesions occur in the neck and monochromatic long-pulse or variable pulsed wavelengths, such as long-pulsed neodymiumYAG or short-pulse and long-pulse, pulsed dye lasers are required.

Procedures such as simple shave excision, chemical or thermal ablation of intra-epidermal papillomas, skin tags, compound moles, seborrheic keratosis, actinic keratosis, and a host of other pathologies can significantly improve the appearance of the neck. Superficial and deep dermal epidermal rhytides can be treated safely and effectively with fractional ablative lasers, CO2, Erbium, and fractional radiofrequency ablative systems. 

Dermal and Subdermal Tightening Devices and Technologies: There has been a rapid evolution in our ability to provide moderate, non surgical skin tightening and wrinkle-reduction therapy with transepidermal energy devices. These new “energy-assisted” nonsurgical skin tightening procedures have become very important drivers of consumer interest. The first generation of the noninvasive skin tightening technologies involved nonfractionated longer wavelength near infra-red laser devices, such as the 1320-nm Cooltouch (Roseville, CA), the 1440-nm Smoothbeam (Syneron Candela, Yokneam, Israel), the long-pulsed Nd:YAG, and the1320 to 1440 nm synchronously pulsed Affirm MPX (Cynosure, Westford, MA).  Monopolar, stamping RF  typified by Thermage (Solta Medical, Hayward, CA), was a next generation very successful device with modest to good skin tightening effects, proven in large multicentered trials. Monopolar thermage protocols for treatment of the neck often includes 2 to 3 passes and 2 to 3 treatment sessions separated by several weeks. Combined optical-bipolar RF devices emerged, such as the Refirm and Polaris (Syneron), showed noticeable improvements using multiple-pass, multiple-session treatment protocols. These mono-polar and bipolar RF or optical-RF combination devices, are “stamping” or “static” in nature and often suffer from inadequate dermal stimulation by a combination of very high peak dermal energy (and hence stimulation) but a very short pulse duration, exposing dermal tissue to a relatively short thermal stimulation that would be required for the production of new collagen, elastin, and ground substances. These stamping devices generally deploy protocols with multiple passes and multiple treatments to overcome the ultrashort pulse duration but high temperature model of collagen production stimulation.  More recently, a whole class of transepidermal RF heating devices have emerged that are not short-pulse duration “static” or stamping in nature, but rather, are continuous wave RF systems that are constantly moved along the surface of the skin along a thin layer of ultrasound or some interface gel. The advantage of these “moving” or “dynamic” RF systems is the ability to heat this tissue to a lower temperature but for a much longer period than pulsed mode stamping technologies and, depending on the “moving” device, the therapeutic thermal end point, usually 42ºC to 43ºC can be maintained, for a very long time. Some of the early “moving RF systems” include the Accent (Alma lasers, Buffalo Grove, IL), Tripolar (Polagen), the diamond polar and Octapolar (Venus Freeze [Venus Concept, Toronto, Canada]), the Excelis (BLT Industries Inc, Framingham, MA), and  moving bipolar thermally controlled and modulated RF device, called the FORMA (Invasix). The FORMA is a very high tech, thermally modulated enhanced moving RF heating device that has built within the hand piece sensors that measure high and low dermal impedance, epidermal temperature, and electrode contact 10 times every millisecond, and automatically adjusts RF energy depending on the sensory feedback. The FORMA will automatically cut the RF energy off when the therapeutic skin temperature is reached, the impedance drops too quickly (temperature is rising too quickly), or the electrodes lose contact with the epidermal surface. Once the epidermis cools to 0.1ºC below the target temperature, the RF energy is turned on again and heating resumes. It can read, modulate, and automate the high and low temperature extremes, keeping the skin at a very uniform and consistent thermal end point, usually 42ºCto 43ºC for prolonged periods of time by this process of thermal modulation and eliminating the “hot spots” that can cause patient discomfort and burns. This thermomodulation process is called ACE, or acquire, control, and extend. Clinical and histological studies using ACE RF devices have shown good contraction and 14% more new collagen, and 35% collagen synthesis up-regulation. Infrared Light (1,100–1,800 nm, Titan, Cutera) have also shown good skin tightening results. Over the past few years, fractional deep dermal ablative devices have been released and commercialized that can result in significant rejuvenation. Ulthera, or fractional HIFU, uses high-frequency focused ultrasound to create ultrasound-induced fractional thermal ablative zones in the deep dermis and, in some areas, the superficial aponeurotic system. Results can be excellent, but occasionally painful and inconsistent. The HIFU can be combined with IPL or other fractional ablative devices at the same session. Deep RF ablative needle devices are also commercially available, which uses RF-emitting needles inserted under local anesthesia to create deep microthermal ablative RF zones that result in remodeling and tightening, while sparing the epidermis, hence risk of postinflammatory hyperpigmentation. The skin-tightening results of the these fractionated, vertical HIFU, or RF systems can be excellent to good, with, in general, one maintenance treatment every 3 to 6 months. Thermally modulated nonablative skin-tightening applicators also can be used safely off the face and in combination with any other injectables and chromophore based laser systems of fractional, ablative RF or laser systems. 

Excessive preplatysmal fat will often compromise a youthful, acute cervicomental angle. There are multiple ways to address submental adiposity in a minimally invasive fashion likes suction-assisted lipoplasty (SAL), ultrasound-assisted lipoplasty (UAL),  laser-assisted lipolysis (LAL) , injection lipolysis using drugs generally based on phosphatidylcholine and deoxycholate (PCDC), carboxytherapy etc.

The aging neck remains one of the greatest challenges for the aesthetic physician. Minimally invasive, nonexcisional techniques to rejuvenate the midface and brow have delivered tremendous success for  over the past 5 to 10 years. Because of its structure, location, and, often, sun exposure, the cervical submental region has presented more challenges to the aesthetic physician in achieving consistent nonexcisional rejuvenation. Over the past few years, with the evolution of subdermal heating techniques and transepidermal fractional ablative techniques, chromophore-based and light-based systems, alone on in combination with subdermal stimulation and suspension techniques, the aesthetic physician now has many weapons and tools to better address the noninvasive and minimally invasive, nonexcisional treatments of the aging neck.

As with any aesthetic treatment, appropriate patient selection and the skill of the physician are key to successful results. As with any machine, it’s only as good as the user. You have to choose the right patients and whoever’s using the machine has to be competent. Research your choice of machine carefully – there is a variety to choose from on the market and there’s one to suit every clinic according to patient requests and budget.  

In my practice I always use a combination approach for lower face and neck rejuvenation for my patients;  botulinum toxin and filler injections with few sessions of fractional radiofrequency and laser treatments,  infrared treatments and injection lipolysis using deoxycholate  and carboxytherapy when needed.

References

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