When we think of aesthetic treatments and antiageing, by default, our thoughts often focus on the face. However, I find that it is the disharmony between a youthful face and an ageing neck and décolletage that is the giveaway of a person’s true age.
In an ideal world, antiageing treatments should take a more holistic approach; combining aesthetic treatments whilst optimising health and wellness. But so often, patients wishing to treat the neck and décolletage only seem to come into clinic once the damage has already been done, leading the patient to seek corrective rather than preventive aesthetic treatment.
Today, patients are well informed of the importance of investing in good skincare, sun protection and starting aesthetic treatments early to optimise their antiageing effects, rather than fighting lines and wrinkles when they appear.
However, despite an increase in patient education, it always surprises me how much the neck and décolletage are neglected. Even where skincare and SPF are applied, the extent of their application tends to stop at the neckline.
The ageing neck
After the periorbital area, the skin on the neck is the most delicate. The neck contains far less elastin fibres compared to the face, resulting in a weaker supporting structure to the collagen matrix. In addition, the neck also lacks fatty structures to give extra support to the less elastic skin. The combined effect of sagging jowls, submental fullness, inelastic skin and the formation of platysmal bands contribute to the loss of the cervicomental angle, which is the hallmark of the ageing neck (Figure 1).1
‘Turkey neck’
The platysma is a vertical muscle that runs throughout the whole neck. It lacks support from surrounding connective tissue, which leaves it practically free-floating. As we age, the muscle fibres of the platysma shorten and contract which creates the classical platysmal bands, which are the most obvious and feared sign of the ageing neck, commonly referred to as ‘turkey neck’.2
‘Tech neck’
We are now living in the world of the ‘selfie’, with increased pressure to look picture perfect 100% of the time. We capture our lives using our smartphones, but constant overuse of technical devices means we spend more time looking down at our phones than looking at each other. The constant head tilt leads to excessive pressure and creasing of the delicate skin in the neck area, which can result in accelerated formation of lines and wrinkles.3
The consultation
As with any aesthetic consultation, the first step is to establish the patient’s concerns. Having an open discussion with the patient and exploring how much the problem affects their life on a day-to-day basis is a good starting point.
Also discussing previous treatments and how long the problem has been bothering them gives a good insight into the extent of the issue. In addition to covering the routine medical assessment, it is also useful to discuss lifestyle factors, in particular, smoking, diet, exercise and skincare regime, including SPF use.
Classically, the main patient concerns related to the neck and décolletage include:
- Skin laxity
- Fine lines
- Wrinkles
- Crepey skin
- Double chin
- Treatment choices
Fortunately, there is a wealth of minimally-invasive treatment options available for treating the ageing neck and décolletage. This is where the value of a thorough initial assessment comes in to guide the best treatment choices for the individual needs of each patient.
Botulinum toxin – ‘Nefertiti lift’
Named after the famous youthful jawline of the Egyptian queen, the Nefertiti neck lift involves injections of botulinum toxin into the lower jaw and neckline.4 The amount of injections is variable depending on the patient in terms of muscle bulk and definition.
This treatment is best suited to patients with early signs of the ageing neck, in particular mild jowling and platysmal bands. Assessment includes visualising contraction of the platysmal bands, which is best achieved by asking patients to bite down on their back teeth. The bands are injected vertically along the neck. It is essential that the depth of injection is intradermal to avoid diffusion of toxin into deeper structures of the neck, which can affect speech and swallowing.5
Dermal fillers
Hyaluronic acid (HA)-based dermal fillers aim to replenish lost moisture and improve volume and elasticity, making them a suitable option for treating the delicate skin of the décolletage. Once treated, the skin appears plumper and the lines and wrinkles are effectively smoothed.6 Compared to traditional HA dermal filler injection, the treatment involves superficial microinjections of filler to create small blebs along the valley of wrinkle.
Don’t be afraid to slightly over-correct, as the cross-linked structure of the HA that is specifically formulated for skin boosters mean it is best suited to treat the skin in the delicate décolletage area. A slightly ‘over-corrected’ appearance will settle with time, and, in my experience, will actually give the best result. It is best to review the results after two weeks. Due to the large surface area of the décolletage, repeat treatments are often needed to achieve optimal and longer lasting results.
There are two main types of thread: free floating cogged or barbed; and suspension threads, which need to be anchored to a stable structure of the face or scalp
The results generally last between six to nine months and how long they last depends on the condition of the skin initially, especially the degree of elasticity and depth of wrinkles.
Threadlift
The threadlift offers an alternative to the traditional facelift in patients with concerns about sagging skin of the neck and jowl formation in the lower jaw. Threads are usually made from polydioxanone (PDO), which are inserted into the dermis to create a mechanical lift, which is maintained by collagen formation.7
There are two main types of thread: free floating cogged or barbed; and suspension threads, which need to be anchored to a stable structure of the face or scalp.8 The choice of thread is decided by the clinical indication, whether it is for skin rejuvenation or elevation of ptotic skin. In the case of the ageing neck, elevation of the drooping neck tissue against the effects of gravity is the main priority and is best treated with a PDO thread.
There are many different techniques that can be used. The number of points needed to create elevation is best decided on a case-by-case basis. Patient selection and management of patient expectations are essential.
Threadlifting, however, has more potential side effects and downtime than injectables. The most common ones being: swelling, haematoma, seroma formation, infection, migration of the sutures, puckering and dislodging of the thread position which may result in asymmetry. If dislodging happens, then this will need review and possible correction.8
As with any aesthetic procedure, it is worth investing adequate time to ensure the patient fully understands the pros and cons, and that the risks and recovery time are acceptable to them before going ahead.
Devices
There are many different devices on the market that have demonstrated results in the treatment of the ageing neck and décolletage. The specifics of each device are worthy of an individual write up to fully explain the complete mode of action.
In summary, however, all devices share the same fundamental action: using thermal energy to create local heating of the dermis of the skin to stimulate fibroblast activity and increase collagen production in the subcutaneous tissues. The increased temperature results in contraction of collagen fibres, which causes contraction of the overlying tissues creating traction on the surface of the skin.9 The overall effect is to tighten and smooth the overlying skin, lifting out fine lines and wrinkles and improving the overall texture of the skin.
The different technologies include:
- Radiofrequency
- Ultrasound
- Laser resurfacing with fractional CO2 laser
Combination therapy
Many of the treatments discussed work best synergistically, so it is useful to explore the option of combination treatment depending on the practitioner’s experience and patient choice.
Other treatments such as platelet rich plasma (PRP) therapy, mesotherapy, microneedling and skin peels can provide great alternative treatments or ‘add-ons’ to the patient treatment regime to support the rejuvenation process.
Summary
Skincare and sun protection are fundamental to maintain the results of the chosen treatment and provide antiageing effects in the long term. Patient education is essential from start to finish of the patient’s journey through their treatment.
Skincare, sun protection and lifestyle adaptations, mainly smoking cessation, diet and reducing alcohol intake are important to improve skin health and weight control, which all have an impact on the ageing process of the neck and décolletage.
The neck and décolletage are all too frequently forgotten when it comes to preventative treatment. As a result, aesthetic treatment in these areas will likely remain commonly sought-after.
Although the neck and décolletage were traditionally challenging to treat, the emergence of high-tech devices, advanced techniques such as threadlifting, combined with the mainstay of injectables and optimum skincare, mean that the a
