Jaw and neck rejuvenation

01 Aug 2014

Many women aged 40-60 want a tighter jaw line and a smoother neck. Surgery is certainly one option, but what else is available to patients who don’t want to opt for such an invasive procedure? Kathryn Senior speaks to practitioners about their recommendations.

Who can benefit from jaw and neck lifting?

Aesthetic practitioners and cosmetic surgeons report that enquiries for neck and jaw work are made mainly by women aged 40 to 60. According to the aesthetic practitioners interviewed for this article, between 80% and 90% of this demographic is female, but this does not mean that the procedures available do not work in men. Surgical and non-surgical techniques have similar effects and satisfaction rates in both sexes. “The treatments that boost collagen production and lift the skin through dermal heating can in fact work better in men as they tend to have thicker skin and more collagen than women of the same age,” comments Dr Patrick Bowler, founder of the Courthouse Clinics, who offers predominantly non-surgical options in his ten clinics throughout the UK.

Making informed decisions

The ageing process varies between individuals. An important first step in advising a patient of the options most suitable for them is to assess both the patient’s physical appearance and their expectations.
Mr Alex Karidis, lead cosmetic surgeon at the Karidis Clinic, based in The Hospital of St John & St Elizabeth in St Johns Wood, London, offers both surgical and non-surgical options. “When a patient first comes to see me I ask them to describe what they want. Those first 5-10 minutes are the key to establishing how the patient views their face and neck, and their expectations,” he says. Mr Karidis does this by asking patients to look at themselves in a mirror and demonstrate how they would like to look. The response varies. “It’s usually clear very quickly if the patient needs surgery – they pull their skin back to demonstrate their need for a drastic change.” Some patients are happy with the recommendation and opt for a surgical procedure, but others do not want to go anywhere near an operating theatre. “Someone who is not keen to follow a surgical path needs to understand what can and can’t be achieved with non-surgical treatments. We don’t want them to spend money on non-invasive treatments if they are not going to be happy with the results,” he adds.
Although patients are important in the decision making process, the aesthetic practitioner is there to provide expert input and direction. “I spend a lot of time asking the patient what they want to achieve, but I don’t expect them to come with a list of procedures and [I] just agree to do them. Patients need our expertise to recommend what is going to have the most impact on their problem – they have a choice, but it must be an informed choice,” says Mr Karidis.

When is surgery the best option?

Cosmetic surgeon, Mr Jan Stanek, is convinced that surgery is the only option for men and women with advanced signs of ageing. “One of the most common complaints is of sagging in the cheeks, jowls and some degree of fullness and sagging under the chin. As the platysma muscle in the neck relaxes, this also causes sagging of the skin down towards the chest,” he explains. “Non-surgical treatments can have only minor effects; if you want significant improvements, surgery is the way forward,” he says.
The jaw and neck are intimately associated with the face, and patients who may think they just need a facelift, are advised to have a combination procedure for a more pleasing effect. “If you tighten up the face without paying any attention to the neck, the result can look very odd because you are treating only one part of the problem. It’s really not worth doing as far as I’m concerned,” stresses Mr Stanek. “I will always be honest with a patient and explain to them what can be achieved with surgery.” Mr Karidis agrees, as does Dr Bowler, who confirms that some patients are beyond the scope of what he can provide. “Even the best techniques that make use of radiofrequency, dermal fillers, Botox, ultrasound or laser therapy, or any combination of these techniques, have their limitations. If a patient has a neck with a lot of loose skin, very little collagen structure and advanced ageing, we recommend they have surgery,” he confirms. In his practice, he regularly turns away patients who want non-surgical treatments but whose expectations are unlikely to be met.

The non-surgical approach

Cosmetic surgery may provide the most drastic reversal in the signs of severe ageing in the neck and jawline but a surgical procedure is not right for everyone. “Some patients just don’t want surgery,” says Dr Bowler, “But they want to achieve some improvements and accept the limitations. We also see many middle-aged women who want to be told they look ‘well’, rather than receive questions about who has done their cosmetic work,” he says. The gradual improvements that can be achieved by non-surgical techniques suit this demographic very well.
Following a programme of non-surgical jaw and neck tightening procedures, over months or even years, can keep the skin and underlying tissues in good condition, delaying the ageing process. “But you only get the maximum effect if you are persistent, attending for regular treatments,” says Mr Karidis. Non-surgical interventions are less invasive and in many cases patients do not have downtime. Many procedures can be done as ‘lunchtime’ appointments and produce no visible adverse effects. “This is a significant advantage to many of the women I see, who don’t want to be out of action and certainly don’t want swelling, bruising or scars,” notes Dr Sam Robson, medical director at the Temple Medical clinic in Aberdeen. Appearance is not the only factor that is important. “Patients that have the Harmony Clear Lift treatment often report that the feel of their skin has improved noticeably, and this is one of the aspects that they are most pleased with. Feeling better and looking better are intimately linked,” says Dr Bowler.

Non-surgical procedures available for the jaw and neck

Devices

Local heating of the dermis causes contraction of the collagen fibres already in the skin at the time of treatment. This causes a contraction of the underlying tissue, which pulls the surface skin. When treatment is targeted carefully, the overall effect is to lift the skin, removing fine lines, making the skin look smoother and more toned. The heat also stimulates fibroblasts in the dermis to produce more collagen; over the course of several treatments this thickens the skin and provides more collagen to work on, so the effects build over several weeks.

Different technologies are available to cause sub-dermal heating:

  • Radiofrequency, eg the Endymed RF system used by Dr Robson, or the Exilis by BTL
  • Ultrasound, eg Ultherapy, favoured by Mr Karidis
  • Laser, eg the Harmony Clear Lift system used by Dr Bowler

Microneedling causes minor physical damage to the dermis, which also stimulates fibroblast activity.

Injectables

Botulinum toxin injections carefully placed in the muscles of the neck, around the jaw and in the lower face, can inhibit contractions of the muscles that pull the skin down. Botulinum toxin works in a completely different way to techniques that cause heating, so can be used concurrently and can accentuate the non-surgical lifting effect. Dermal fillers add volume underneath the skin, and can reduce the appearance of jowls and smooth folds around the mouth and creases around the lip line.

Threads

Absorbable ‘threads’ are used to lift and realign sagging tissue and work to support the neck. The surrounding tissues hold the threads in place, eliminating visible scars. French cosmetic doctor Dr Jean-Louis Sebagh, who uses Silhouette Soft to perform this treatment, says, “There are a number of benefits to the patient when using Silhouette Soft to lift and tighten the neck and jaw area. It does not require a general anaesthetic and the treatment itself can be performed in 30 to 60 minutes. In addition, as the procedure requires no incisions to be made, the downtime and recovery is minimal, with the patient feeling well immediately after treatment and any potential downtime is limited to a week or so – unlike surgery which comes with a recovery time of six weeks plus.
“The results last for up to 18 months – thanks to the threads being made of polysaccharide, they gradually dissolve over a 12-18 month period but the collagen that is created after the treatment is carried out helps to extend the period of lifting and tightening. For some patients, Silhouette Soft will allow them to delay or even avoid the need for cosmetic surgery, which is excellent news. If carried out correctly by an experienced doctor, the results are remarkable and rewarding.”



Combination treatments

Different practitioners have their own views on what works best for which patient, but most incorporate some type of energy device. “Radio-frequency, ultrasound or deep laser treatments heat the underlying tissues, stimulating the formation of new collagen, which leads to shrinkage and tightening of the skin. That’s the basic premise on which these energy devices work,” explains Mr Karidis. Like any interventional process, a balance between sufficient heating to have a positive effect and too much heating that could cause burning, is essential. “Today’s technology can target the tissues in a very precise manner but even so you can get burning, so you have to accept shorter treatment times and lower settings for the maximum therapeutic effect without damage,” he adds.


The field certainly seems to be moving in the direction of combining multiple treatments, either concurrently, or over a period of months. The techniques work in different ways, targeting different tissues and processes, so do appear to have a cumulative effect.
Mr Karidis personally avoids radiofrequency because of what he deems its ‘scattergun’ approach, and favours Ultherapy. “I prefer ultrasound because of its precision. You can focus exactly on the depth and area that you want to target and you can use fewer treatments. It is very useful for sculpting the jawline and neck area,” he comments. Ultherapy is used in combination with other treatments in patients who don’t want surgery and also in those who have had a surgical face and neck lift. “It’s not all about just lifting the skin. That’s where Botox and fillers and skin peels go hand-in-hand. I use the non-surgical treatments after surgery for maintenance in the years following. It’s an on-going process,” he explains.
In Dr Bowler’s practice, the emphasis is on a bespoke treatment plan for each patient, which can involve injections of botulinum toxin, dermal fillers based on hyaluronic acid as well as the Harmony Clear Lift laser system that he favours. “The Harmony Clear Lift system is fairly new technology but we have treated many patients now and we are impressed,” he comments. “Not all patients are suitable; the laser used within the system causes a targeted heating effect that stimulates fibroblasts to produce more collagen, but if a patient has very little collagen left in their neck, it is unlikely to achieve very much,” adds Dr Bowler.


Dr Robson’s preferred treatment for tightening up the jawline is to use the Endymed RF system but within a combination protocol that also offers fractional resurfacing, microneedling, Skinboosters, Ominlux, botulinum toxin, dermal fillers, PRP and surface skincare. “We are currently devising a complete non-surgical facelift that can be applied to anyone, but predominantly aimed at women aged 40 to 60. The treatments are done over several months and everyone will see at least some improvement since we are stimulating collagen production, restoring lost volume and improving skin health,” she reports.
Robson is confident that all patients can benefit from non-surgical treatments, even those with marked signs of ageing. “If someone does not want surgery, there is still plenty that can be done. It is a matter of expectation,” she notes. “Patients need to understand that improvements will be gradual and that there are limitations.”

Case study: example combination systems

Although aesthetic practitioners are devising their own bespoke combination treatment protocols, some manufacturers have also developed treatment systems that combine different modalities.

Alma’s Accent Ultra V

Technology involved: Combines cavitational ultrasound with high power radio frequency for deep thermal heating.
Treatment details: Cold ultrasound sheer waves are applied to the neck and jawline. This breaks down fat cells, which are large (50-150 microns) and so easily shocked by the vibration, but leaves the smaller cells that make up blood vessels and nerves (5-15 microns) undamaged. This is followed by an application of radiofrequency for deep heating, which increases the metabolism and stimulates collagen production.
How long does it take? Approximately 30 minutes.
How many treatments? Four to six sessions, each two weeks apart.
Advantages and benefits: Can be combined with other treatments. Can be adjusted to the individual needs of the patient.

Harmony Clear Lift

Technology involved: Deep thermal non-ablative laser that targets the layer of skin up to 3mm below the surface. It leaves no surface effects.
Treatment details: A Pixel Q-switched laser targets the deep dermis using multiple fractions of energy. This encourages collagen production, which has a tightening effect.
How long does it take? Approximately 30 minutes.
How many treatments? Three to six sessions, each two weeks apart.
Advantages and benefits Can be done as a lunchtime treatment and effects can be noticeable immediately and then build over the weeks of treatment. Most practitioners advise a follow-up treatment six to twelve months later for maintenance. Improves skin texture and reduces pigmentation.

Sygmalift

Technology involved: A combination of high frequency ultrasound and a 635nm laser.
Treatment details: The HIFU line probe remodels fat effectively while the Trimicro focal ultrasound probe produces local heating in the dermis to stimulate collagen production. The LLLT probe stimulates deeper skin layers.
How long does it take? Approximately 30 minutes.
How many treatments? Three to six sessions, each two weeks apart.
Advantages and benefits A treatment that can be done at lunchtime with no visible adverse effects. The coupling of the laser and ultrasound produces a glow to the complexion, as well as underlying changes in collagen.


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