Special Feature: Treating the Submental Area

By Kat Cooke / 04 Jan 2018

Aesthetics speaks to practitioners about their different approaches for reducing the appearance of a double chin

A study published in 2017 suggested that 47% of adults are bothered by the appearance of the area under their chin. Of the 1,996 survey respondents, 35% said they shy away from photos because of their double chin and 29% of men claimed to have grown a beard to hide the region.1

It is an area of concern for many, and one that cannot be easily hidden or camouflaged. The five practitioners interviewed for this feature all agree it is one of the most common complaints patients have regarding their appearance and one that is also on the rise.

In this feature, practitioners share their preferred approach to treating submental fullness, from cryolipolysis to fat dissolving injections.

Assessment

According to aesthetic practitioner Dr Galyna Selezneva, before any treatment options are discussed, the practitioner must distinguish if the submental fullness is caused by fat or skin laxity. She explains, “Some patients have skin laxity which they perceive as a ‘double chin’, and for that I would do a skin tightening treatment. However, if my analysis shows me it is fat, then I will discuss treatment options for addressing the fat.” She stresses the importance of checking the patient’s medical history, as this gives a good insight as to whether the double chin has been there since the patient was young, despite an otherwise healthy weight, or if it’s new. “I always use a 3D image device to take a photo, so, together with the patient, we can view the submental area from all angles,” she says.

Aesthetic practitioner Dr Darren McKeown says it’s also important to recognise when the patient may require surgery. He explains, “I assess the degree of the problem and the amount of loose skin, fatty tissue, underlying musculature, as well as the degree of improvement they are hoping to achieve. If they are looking for a really sharp, defined jawline and a significant improvement, I advise that the only way to do that is with a surgical approach and will refer them to a surgeon.” If a patient does not want surgery and is willing to accept a less significant improvement, then Dr McKeown states that he will begin discussing the non-surgical treatments available.

Treating the submental region

Aesthetic devices which lower or raise body temperature, to target unwanted fat and skin laxity, are becoming more present in aesthetic clinics as technology evolves and becomes more effective. So, what devices are practitioners using for the submental region?

Heating

Using targeted heat to destroy fat cells is one way to eliminate submental fullness. One device that does this is body contouring laser device SculpSure.2 Mr Faz Zavahir, medical director and plastic surgeon, has been one of the first practitioners to use the device for the submental region in the UK. 

He explains, “This treatment uses light energy to destroy the fat cells found under the chin. The SculpSure submental applicator is designed for the precise treatment of the chin and neck area for a contoured profile.” The device, which recently received a CE mark for this indication,3 uses a wavelength of 1060 nm, which raises the temperature of the adipose cells between 42-47°C, damaging the structural integrity of the fat cell. Over the next three months, the body naturally eliminates the disrupted fat cells.2

“It’s a 25-minute treatment, with no downtime needed,” says Mr Zavahir, adding, “There are no noted side effects except perhaps a little soreness and redness immediately afterwards. It is, however, a comfortable treatment which involves no recovery time so the patient can go back to work straight away.” Approximately one to three treatments, scheduled six weeks apart, are needed to see a noticeable difference, according to Mr Zavahir. He says that, because the fat cells are destroyed during the treatments, patients who are maintaining a heathy weight and lifestyle will see permanent results. 

Figure 1: Patient treated for skin laxity using the Profound device. Before and six months after treatment

While most US Food and Drug Administration (FDA) approved body contouring treatments only have approval for patients with a BMI of 30 or lower, this is not the case for SculpSure, Mr Zavahir points out. “SculpSure submental treatments are FDA approved for patients with a BMI of up to 43.4 Although, prior to treating the patient, it is important to discuss their goals and review medical history to determine if this is a suitable treatment,” he notes, as some patients may be more suited to surgical treatment if they require a substantial reduction.

Aesthetic practitioner Dr David Jack uses an array of heat-based devices in his clinic for treating the submental area for skin laxity. He says, “If the patient has the appearance of a double chin due to skin laxity, then there are a number of different treatments which work well. I use Fractora, which is a fractional radiofrequency (RF) device that causes injury to the skin to stimulate bioremodelling.” Fractora delivers RF energy to the skin through an array of pins which produce localised heat and small micro-lesion dots in the treatment area. The heat, generated by the Fractora pins in the sub-dermal tissue, promotes collagen restructuring for skin rejuvenation and an improved appearance in the skin.5 “I have also started to use Profhilo a lot in combination with Fractora, which is a 1,4-butanediol diglycidyl ether (BDDE)-free stabilised hyaluronic acid injectable for treating skin laxity. I find it helps with skin quality, to improve the surface of the skin in that area. I always believe that combination treatments deliver the best overall results.” 

As Fractora is a fractional treatment, there is a risk of redness and scabbing afterwards, and possibly some swelling. “There is a very low risk of burns because it is a controlled treatment; you are not heating the skin permanently in one area,” says Dr Jack. “It all depends on the patient’s skin type, too, as the darker the skin, the more risk of pigmentation changes. So, I would really only use it for Fitzpatrick skin types I to IV.”

Dr McKeown’s device of choice is the Profound microneedling and radiofrequency device, which he explains can be used for both skin tightening and fat reduction in the submental region. He says, “Profound is an energy-based device that uses heat to stimulate collagen contractions. It heats the dermis to 67 degrees and works by inserting microneedles 4mm deep into the dermis, which then delivers RF energy with accurate control.” He says that the practitioner can control the length of time the tissue is held at that temperature for, with the optimal time being four seconds. 

He explains that Profound has two handpieces – the Dermal and the SubQ head. “The SubQ head is specifically designed for melting fat in the submental region,” says Dr McKeown. “It goes a little bit deeper to treat the subcutaneous fat; so, if I’m treating a ‘fatty neck’, I use the SubQ first, melt the fat, and then use the Dermal head to tighten the skin.”

Figure 2: Patient before and 12 weeks after second cryolipolysis treatment. Photos courtesy of A. Jay Burns, MD

The treatment is performed under local anaesthetic and each handpiece has ten microneedles, which are then inserted into the skin, via a finger trigger, with the standard protocol for a dermal treatment being 150 insertions. “Throughout treatment, the needles come out of the applicator head and treat one section at a time,” explains Dr McKeown. “The treatment takes around 40 minutes in total and there is a little bit of downtime as, because of the temperature, there can be a lot of swelling afterwards.” He advises patients to have the treatment on a Friday, have the weekend to recover and then go back to work on the Monday. However, there can be subtle swelling for two weeks after.

Like any energy-based device, there is the possibility of burns, scarring and changes to pigmentation – either hyper or hypo – but Dr McKeown has never experienced these issues first-hand. “To avoid complications such as these, you have to be careful when inserting the needles and check they are in the skin at the right angle. The tip of the needle, the part that is delivering the energy, needs to be fully in the skin before application,” he says.

Dr McKeown says patients are usually pleased with their results, but stresses the importance of managing patient expectations. To explain the results that can be achieved with Profound, he tells patients to imagine what they might get from a facelift and then imagine a third of that improvement. He explains, “Syneron Candela conducted a study where they compared the outcome of Profound to the outcome of a surgical facelift and the patients in the study achieved approximately one third of the improvement of the patients who have had surgical facelifts. So, this is how I describe it to my patients.”10 Three month’s post treatment with Profound, Dr McKeown says that approximately 80% of his patients are satisfied, and, after six months, around 90% are satisfied.

For just skin tightening, there is no definitive answer as to how long results will last using the Profound, explains Dr McKeown, but he tends to tell patients to expect two years, as that was the longest outcome portrayed in a study.10 “My suspicion is that after you have generated new collagen, patients’ skin will always be better than if they hadn’t had the treatment done. But we haven’t proven that scientifically yet,” he adds.

Cooling

Devices that use a low temperature to target fat cells are also effective at reducing submental fullness. Dr Selezneva’s treatment of choice for fat under the chin is a cryolipolysis device. Once she has undergone a thorough medical assessment with the patient and ruled out any contraindications, such as Raynaud disease (a medical condition in which spasm of arteries causes episodes of reduced blood flow), she will discuss the best time for treatment. “There is very little downtime,” she explains, but in some cases, there is swelling, mild bruising and redness for an hour or so straight after treatment, so it’s best to make sure the patient has no big social events coming up.”

Most patients will need just one applicator placed under the chin, but depending on the size and position of the problem area, patients might need two or even three applications in one session. “If the patient needs two applications, I would do one after another, overlapping the central area, as that is predominately where we carry the majority of the fat. In one session the treatment takes 45 minutes and, once the first application is complete, we remove the applicator, massage the area, and straight away put the second applicator on.”

The moulded cup uses suction to draw tissue into it to cool it down. “The cool temperature crystallises the fat cell,” Dr Selezneva explains. “The fat cell becomes a dead fat cell and the body no longer recognises it and instead sees it as debris. The body then sends scavenger cells to secrete it.”6

On average, Dr Selezneva says her patients usually see a 25% reduction in fat and that, as long as they don’t have any significant weight gain in the future, results should be permanent

During the treatment, patients may feel discomfort, but Dr Selezneva says it shouldn’t be painful. “When the temperature drops, the nerve endings go to sleep and go numb, so no additional numbing is required.” She adds, “Some of my patients sleep whilst having the treatment, but the majority read a book or look on their phones.”

Dr Selezneva will review the patient four weeks post treatment and, at that point, it will be decided whether or not the patient will benefit from a second treatment, although she says that one treatment is enough for most patients and very rarely would a patient need a third. The patient should be made aware of the possibility they may need extra treatments during the initial consultation.

“In the submental area, patients start to notice the difference after two weeks, and then results progressively get better over four to six weeks, although in some cases I have seen progression up to two months afterwards.” On average, Dr Selezneva says her patients usually see a 25% reduction in fat and that, as long as they don’t have any significant weight gain in the future, results should be permanent.

When asked what the main side effects or complications are, the main concern for Dr Selezneva is poor application. “I have unfortunately seen some wrong applications, where dents have occurred and the results are uneven,” explains Dr Selezneva. “That can be avoided with proper placement.” She notes that to resolve this issue can be a complicated manner, and possibly can be corrected with further cryolipolysis treatment, but this is decided on a patient-by-patient basis. Other reported side effects include temporary redness, swelling, bruising and skin sensitivity.7

Carbon dioxide therapy

As well as heat-based devices, Dr Jack uses carbon dioxide (CO2) therapy, also known as carboxytherapy, to target and destroy fat cells under the chin and tighten loose skin. “There are two applications for carboxytherapy,” he explains. “It can be used in the skin for the treatment of stretch marks, fine lines and wrinkles, where you inject into the dermis with a tiny needle, it passes pure carbon dioxide under the skin and it is heated to body temperature. The second, is that you can inject it into the subcutaneous fat, which is a slightly deeper injection, and the high CO2 levels are toxic to the fat cells. This induces cell death so you get a reduction of fat cell volume.” 

Patients will need to have one treatment a week for ten weeks, but Dr Jack says in his experience they can expect to see a 20-30% reduction in fat. He explains that for superior results, he offers a combination of treatments. “You can do a cryolipolysis treatment, leave for a few weeks, then do carboxytherapy or radiofrequency, and again, do a series of treatments,” he says. “Or, you can do carboxytherapy, reduce fat cell number gently, then do cryolipolysis to really top it off. Using combination treatments, particularly for fat reduction, can get really good results,” he notes.

Fat dissolving injections

For practitioners who prefer using needles to devices, another way to tackle fat in the submental area is with deoxycholic acid. Aesthetic practitioner Dr Sarah Tonks has carried out this procedure on many patients. She explains, “The product I use is Aqualyx, which I mix with lidocaine, and then inject at least 10ml of fluid into the tissue. The product makes the fat cells lyse and release the fat, before the body naturally disposes of them.”8

Treating patients with a small pocket of fat is ideal, according to Dr Tonks, rather than someone who has a very large double chin. She explains that the recommended method for under the chin, from the manufacturers of Aqualyx, is one injection point and then a fanning technique.

“Patients frequently misjudge how long they will be swollen for. It doesn’t matter how many times you tell them ‘from my experience you’re going to be swollen for up to three weeks’ – and I’ve seen it happen for longer – people presume they will have the best-case scenario"

Dr Tonks advises that patients have quite a lot of swelling afterwards due to the amount of fluid injected. “When patients leave the clinic, they do look reasonably swollen,” she says. “Then, a tissue response occurs, and they get swelling that becomes hard and quite ‘woody’ due to inflammation. I’d say they have that large swelling for maybe five days and then it starts to dissipate over a couple of weeks,” she adds.

This swelling, Dr Tonks explains, tends to be underestimated by a lot of patients, who are informed of it occurring during the consultation. She says, “Patients frequently misjudge how long they will be swollen for. It doesn’t matter how many times you tell them ‘from my experience you’re going to be swollen for up to three weeks’ – and I’ve seen it happen for longer – people presume they will have the best-case scenario. So, patient management can be tricky.” As with the energy devices that target fat, once the fat’s been dissolved, it shouldn’t come back. “

Once it’s gone it’s gone,” says Dr Tonks, adding, “But you do sometimes have to do more than one treatment session, depending on how much fat the patient has.” The treatment doesn’t take long to perform, and Dr Tonks will allow for half an hour to consult with the patient and perform the treatment.

The main complication to be aware of for Aqualyx is tissue necrosis, Dr Tonks says, “If you inject too much, too superficially, and you’re not spreading the product out enough, there will be tissue breakdown. This can be avoided by making sure you are spreading the product evenly under the skin when you are injecting – you can’t put too much in one area and don’t go too superficially.”

Within three to six weeks, patients will start to see results, according to Dr Tonks, adding that ‘patients tend to get a mild to moderate improvement, as well as some skin contraction’.

Keeping up with demand

The practitioners interviewed agree that the demand for non-surgical treatment of the submental region will only increase, and Dr Selezneva believes this could be related to a rise in the ‘selfie’ culture. “I notice more and more that patients bring photos of themselves, as it’s something they have noticed more in photos. I absolutely believe the demand will continue to grow and the industry will carry on aiming to make treatments less invasive for this area,” she explains.

Dr McKeown concludes, “I think when it comes to the face, we can manage pretty much most concerns non-surgically, but the submental region is the one area we still struggle with in terms of non-surgical treatments. However, with the technology improving in the way that it is, and if we continue to make improvements, I think we will see more of a shift from surgical to non-surgical treatments for the neck and submental region.” 

References

  1. Survey indicates impact of double chins, Aesthetics (2017) <https://aestheticsjournal.com/news/ survey-indicates-impact-of-double-chins-on-self-perception-and-behaviour?authed>
  2. Juvea Medical first UK clinic to offer Sculpsure submental treatment, Aesthetics, (2017) <https:// aestheticsjournal.com/news/juvea-medical-first-uk-clinic-to-offer-sculpsure-submental-treatment>
  3. Hologic, Hologic Recieves CE mark to market SculpSure for non-invasive body contouring lipolysis of the submental area under the chin, (2017) <http://investors.hologic.com/2017-10-17-Hologic- Receives-CE-Mark-to-Market-SculpSure-R-for-Non-Invasive-Body-Contouring-Lipolysis-of-the- Submental-Area-Under-the-Chin>
  4. Macaela Mackenzie, Laser Treatment SculpSure Is Now Cleared by the FDA for Use on Double Chins (2017) <https://www.allure.com/story/sculpsure-fda-approved-for-chin>
  5. Invasix, Fractora, (2017) <https://www.invasix.com/Fractora_7/>
  6. CoolSculpting, How it works, (2017) <http://www.coolsculpting.com/what-is-coolsculpting/how-it-works/>
  7. Healthline, Understanding the Risks of CoolSculpting, (2017) <https://www.healthline.com/health/ coolsculpting-risks#risks-and-side-effects>
  8. Roberto amore, Hernan Pinto, Kostas Gritzalaz et al. Intralipotherapy, the State of the Art, <https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC5096534/>
  9. Kythera Biopharmaceuticals, Kythera Biopharmaceuticals Announces FDA Approval of Kybella (also known as ATX-101)– First and Only Submental Contouring Injectable Drug, (California: MyKybella. com, 2015) https://mykybella.com/wpcontent/uploads/2015/04/KYTHERA-FDA-Approval-Press- Release-4.29.15-FINAL_.pdf
  10. Alexiades et al. Blinded, Randomized, Quantitative Grading Comparison of Minimally Invasive, Fractional Radiofrequency and Surgical Face-lift to Treat Skin Laxity, Arch Dermatology, Vol 146 (No.4) 

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