Concerns and consultation
This 52-year-old female is a regular patient, having facial aesthetic treatments for many years. Her treatment plan includes regular botulinum toxin treatments, bioremodelling, dermal fillers and medical-grade skincare. She booked a consultation to explore treatments for her neck. The patient described herself as peri-menopausal and felt that the loss of collagen and elastin she was experiencing was becoming more obvious on her neck, partially as a result of having focused her treatments on her face. This was the motivating factor for the consultation. Casabona et al. have supported this patient’s assertion, suggesting that the availability of botulinum toxins and dermal fillers to address the ageing process in the face may lead to a stark contrast with the neck and décolletage, revealing a person’s age and consequently becoming a significant aesthetic concern for many patients.1
A full and comprehensive medical history, including mental health, social and economic factors was undertaken. I ensured that the assessment documentation was contemporaneous and included evidence of the treatment options available. The risks and potential outcomes were also discussed and understood, including options for treatment, ensuring the option of no treatment was raised.
From a legal standpoint, the landmark case of Montgomery vs. Lanarkshire Health Board in 2015 is of paramount importance when consenting a patient. This requires that reasonable care is taken to ensure that the patient is aware of any material risks involved in the recommended treatment, and of any reasonable alternative or variant treatment.2 Practitioners have a duty to ensure the patient understands all aspects of the potential procedure, which should be included in the documentation with signed consent forms and reproducible photographs.3
Ageing of the neck
A youthful neck is observed to be clearly defined, have good skin tone, a well-defined mandibular border, appropriate chin projection, and a well-defined cervicomental angle. From the frontal view, there is an absence of horizontal rhytids and no accumulation of submental fat.4-6
The contour and shape of the neck is an important aspect of medical aesthetics. The appearance of transverse neck lines and vertical neck bands are both a result of platysmal muscle hyperactivity, appearing with age as a result of both intrinsic and extrinsic ageing.
Loss of soft tissue support often increases skin laxity, resulting in creases developing perpendicular to the muscle action direction. In turn, the less elastic platysma of an ageing neck attempts to provide the support resulting in active and over-taut muscles visible as bands, forming the pejorative, ‘turkey neck’ appearance.7
The patient’s neck had evidence of skin laxity, dehydration, platysmal bands and the transversal lines of her neck were starting to become more apparent. Whilst the patient didn’t ruminate on her ageing neck, she was concerned about it and wanted it addressed. Her primary concern was the appearance of the skin on her neck, and she described her primary treatment goal would be one of increasing hydration, which she felt would then be in keeping with her face. Setting realistic expectations with the patient is always critical, and contributes to patient satisfaction.8 Through the ageing process, the physiology of the skin undergoes a number of changes, leading eventually to chrono-ageing. Skin laxity is a phenomena occurring early in the ageing process and is related to the loss of elastin and collagen. It’s also associated with alterations in the extracellular matrix (ECM), particularly with a reduction of hyaluronic acid (HA) concentration.9
HA is a naturally-occurring component of the extracellular matrix; it is a glycosaminoglycan (GAG) polymer, composed of alternately repeating units of D-glucuronic acid and N-acetyl-D-glucosamine.10,11The largest amount of HA resides in the skin tissue; consequently, approximately 50% of the total HA in the body is found in the skin.12
Treatment options
Minimally-invasive procedures have revolutionised the treatment paradigm in cosmetic medicine, resulting in innovative approaches to treatment, multi-modality approaches and increasing safety profiles with good aesthetic outcomes for patients.13
We discussed a number of potential non-surgical modalities to treat the patient’s concerns regarding her neck, with many offering the opportunity to have a combined approach. Along with others, options include neurotoxin, dermal fillers, skin boosters and energy-based treatment.
Profhilo was also considered for this patient. Unlike many other HAs, which are made from a polysaccharide and are either cross-linked, non-cross-linked, mono phasic or biphasic gels, this product is stabilised through a thermal process and does not use chemical cross-linking. The product has unique characteristics such as high such as high HA concentration (64mg/2ml), low viscosity, high manageability, optimal tissue diffusion and a low inflammatory response. It has also been evidenced to reduce skin laxity and increase elasticity and consistency of soft tissues.9
This product was of interest and suitable for the patient because it is indicated for treatment of the neck, using a specific technique – the Bio Aesthetic Points (BAP) neck technique – for remodeling and improvement of skin laxity of the malar and submalar area. Profhilo has two molecular weights, which protect each other from enzymatic degradation, prolonging the duration of effect, as when compared with traditional biostimulation.14 The patient’s face had also successfully been treated previously and she had been thrilled with the results.
Treatment
The procedure was undertaken utilising an aseptic technique. The fundamental principle of an aseptic technique incorporates protecting key elements of the equipment in order that they remain free from micro-organisms, for example, the barrel of a sterile needle.15 These ‘key parts’ and ‘key sites’ are critical components of any invasive procedure. If contamination occurs, this may result in the patient acquiring a preventable infection.
Key parts are defined as equipment used in the procedure that come into direct or indirect contact with another key part or site. Key sites include insertion sites and puncture sites. Both key parts and key sites always need to be protected.16 Figure 1 provides the principles of aseptic technique.
Preparation for treatment included:
- Taking suitable photographs for progress documentation
- Cleaning the treatment area
- Re-consenting the patient verbally
- Marking the treatment area (Figure 2)
Profhilo is usually delivered via the BAP technique, at the level of deep dermis. This technique has been specifically designed for this product, aiming to minimise risks and maximise HA distribution, whilst reducing the number of intradermal injection points and treatment sessions required.18
The 10-point neck technique was developed in order to provide reproducible points of injection, to standardise these points irrespective of variations between patients and ensure that the injection points avoid potential injury to vital structures. In my experience, both techniques reduce pain, downtime and the number of treatment sessions, making it quick and non-invasive.
This injection technique is recommended for all other areas, taking into the consideration the product’s high spreadability values.14,18-20 Using a 29 gauge needle and prefilled syringe, 2ml of Profhilo was administered following the 10 point neck BAP technique, with 0.2ml to each point. The patient tolerated it well, commenting that the neck was more comfortable than the face. The treatment took approximately 20 minutes.
Post procedure
Following the procedure, I took photographs of the results and added them to the patient’s clinical records. I then re-cleansed the skin using Clinisept+, and applied Teoxane Post Procedure Soothing Aftercare Fluid, as well as Heliocare 360 Mineral Tolerance Fluid SPF 50. Immediately after the treatment, there were visible, small swellings, which is normal and the patient was advised that these would subside within 24 hours. I then outlined the general aftercare advice of avoiding makeup, touching the area and not exercising for 12 hours, while emphasising the importance of using sun protection, before agreeing a date for the next treatment and review with the patient, which was four weeks later, in line with the protocol.18
Side effects/complications
In my experience, Profhilo, when administered using the BAP technique, offers a good treatment option to restore vitality in ageing skin. Side effects are limited, with bruising and small wheals at the point of injection being most common,18 which I find usually dissipate within 24 hours. A post-treatment aftercare card with product label was given to the patient, with the normal advice to contact the clinic if she has any concerns, which she did not.
Conclusion
There is an increasing interest in treating the ageing neck with non-surgical interventions. Treatment of the neck is pivotal in the overall rejuvenation approach and, in my experience, can really benefit patients. Of course, it is important to discuss all potential treatments with your patients to ensure you offer options that suit their individual requirements and budget.
