A Systematic Approach to Non-Surgical Neck Rejuvenation

Gabriela Casabona shares her seven-step approach to treat skin laxity and restore volume to the neck

December 27th 2022 | Minimally Invasive, Injectables, Aesthetic Features

A Systematic Approach to Non-Surgical Neck Rejuvenation, by Dr. Gabriela Casabona et al. 

Aesthetic procedures can have a positive impact on self esteem and therefore improve lifestyle; rejuvenation of the neck is a highly popular request from patients seeking improvement of their appearance. When approaching aging of the neck we have to inform patients that the problem is not just an issue within the skin but is due to a combination of aging in other areas such as the mid-face, mandible (lower jaw and mouth) and temples. To therefore understand the aging within each layer; SMAS (Superficial Muscular Aponeurotic System; a thin fibrous layer covering the anterior face and neck), skin and fat is vital to be able to evaluate and determine a plan for each patient when considering energy based devices, threads, biostimulators, or fillers. 

In 2019 a study was carried out using 200 patients whereby the ageing of the SMAS, superficial and deep fat layers in different age groups, gender and BMI (body mass index). Im 2022 a similar study was carried out but this time included skin thickness as a variable. Both studies concluded that, with age, the SMAS became more superficial in specific areas such as; pre-auricular (in front of the ear), submandibular (lower jaw and mouth), and neck due to the loss over time of superficial fat layer, as well as an evident age-related thinning of the skin especially in the neck. 

Therefore, when addressing neck rejuvenation in a patient over 45, it is more likely that the skin will require thickening as well as to add support to the skin below the dermis by adding or restoring the lost fat layer. For this the combination of : PRP, micro needling or radio-frequency can be used for the skin, plus HA (Hyaluronic Acid) or Bio-stimulators to restore the sub-dermal layer (or any other layer) in order to cover the ageing process holistically. 

The anatomy of a patient also assumes an important role in making a responsible decision for the treatments used. In 2019 Casabona et al highlighted the importance of the order in which the areas of the face are treated makes a significant impact on the effectiveness of the treatment as well as the amount of product required.  The same applies for the neck; treatments in posterior temples and lateral face affect the lower face, or more precisely in mandible area, as much as treatments in the chin area also improve the submandibular area. 

We observed the results from a pool of Ocean Clinic’s neck rejuvenation patients over the last five years and recognised that each was satisfied when there was a certain pattern in their treatment plan. It was very important to understand and consider what the patient really wants and how much they are willing to invest to get there, as well as how much post-procedure downtime they can afford. Using a scale helps to visualise a language and reference point for patients to gauge their own severity and pinpoint whether they have a lack of volume or laxity. Over the last 5 years at Ocean Clinic we have developed a systematic approach to evaluate a patient to ensure that the treatment plan we construct for them is more precise and accurately meets the patient’s expectation. Considering the fact that most patients have high expectations in the improvement of their neck laxity and/or volume we developed the following seven steps to follow for assessment and development of combination techniques.  

STEP 1- Choose regions to treat (the more severe the case, the more regions involved). Consider the anatomy in order to understand the impact each region will have on the rest -  e.g., treatment of the zygoma area has a great impact on the mandible area, and, after treatment of the posterior temples we see a great impact in the lateral face; zygoma and  mandible regions will therefore impact in the upper neck. 

STEP 2- Choose vectors; during the ageing process we experience the loss of bone, fat, and skin thickness, each of which have a different impact in the vectors against gravity, and so each region of the face has more important vectors to treat. For lower face and neck rejuvenation, the vertical and horizontal vectors are more important than the projection. (FIG 2) Specifically for the neck, the vertical vector means either to enhance the vertical height of the mandible or to shorten structures such as the SMAS (Platysma + fascia) from mandible to clavicle, and horizontal vectors - to create some shortening in the direction of the back the neck by strengthening the SMAS - skin connection or creating skin retraction. The only projection vector that can affect the neck is the width enhancement of the chin or masseter, but those can be only performed in few individuals with that kind of need.

STEP 3 - Identify the problematic layer: bone, fat, muscle, fascia or skin. 

STEP 4 - Choose treatment according to the vectors: every procedure we do strengthens or weakens a different vector against gravity. E.g., if we inject a bolus of HA (Hyaluronic Acid) in the zygoma area we strengthen the projection effect, whereas if you inject CaHA dilute in lateral face, you strengthen the horizontal vector of the face. Or, if you inject the same HA in lower border of mandible, we strengthen the vertical vector. (Figure 3,4)

Figure 4 (A) was taken during injection of a patient for projection of zygoma with CaHA in bolus on the bone. 

(B) was taken during injection of CaHA dilute in subdermal plane for biostimulation.

STEP 5 - Choose the layer to treat according to best use of the products. Sometimes one product has a better projection capacity if used in the supraperiosteal area instead of in the subdermal area. The use of a bolus rather than retrograde injections have a better projection capacity. (Figure 4)

 

STEP 6 - Choose the amount of product to use depending on the severity (Figure 5)

STEP 7 - Choose a maintenance plan depending on the severity (Figure 5). 

After the step-by-step approach for treatment, the next step is to follow-up with our patients through their journey and to monitor results, but also to follow up in the short term to prevent any possible complications. Depending on the procedure there is a specific time that should be respected for immediate and long term follow up, for example: filler injected should be followed up the next day to check for any lumps, pain, bruising or discoloration, to guarantee there is no complications. For toxin injection follow up occurs around day 15 as this is when any major complications can present, such as ptosis, asymmetries and lack of result. 

figure 6

Figure 6 (A) Before and (B) after 1 year of combination treatment: Ulthera®(Merz Aesthetics, Germany), Radiesse® (Merz Aesthetics, Germany) dilute 1:1 and Belotero Soft® (Merz Aesthetics, Germany) taking place on the same day.

When severity differs, different goals and different layers are involved and so patients will be given contrasting treatment plans and combinations of treatments. This illustrates very well how complicated the decisions for neck rejuvenation can be.

The conclusion from these studies show that is that is vital to be systematic not only in the evaluation of neck aging, but also when electing procedures and the specifics for each patient; each decision makes a difference to the amount of product required and time needed to achieve optimal, desired results. 

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