Dr Aamer Khan provides an overview of the procedures available that aim to improve the appearance of sun damage and ageing on the chest
‘The décolletage is the upper part of a woman’s torso, comprising her neck, shoulders, back and chest, that is exposed by the neckline of her clothing’.1 While we could refer to this area as the chest or the cleavage, the world of aesthetics chooses to adopt the French approach and call it the ‘décolletage’. Unfortunately whatever fanciful terms we use, the décolletage presents a significant aesthetic concern for many women. Whether women have chosen to undergo anti-ageing treatment or simply employ the use of moisturisers and make-up over the years, they have long addressed the fine wrinkles, heavier lines, and skin pigmentation issues that affect the face; only to let the appearance of their chests give their age away. A crepey décolletage can reveal a woman’s age just as easily as her hands; think crinkly chests, lines between the cleavage, and the dreaded age spots. Yet I am constantly surprised by how many women we see in our clinic who have neglected their décolleté and think skincare or sun protection stops at the chin.
After the eye area, the décolletage is the most prone to ageing on the body; more delicate than our complexion as it doesn’t produce as much oil in women due to fewer hair follicles, when compared with men,2 as well as being the first place to develop wrinkles.3 This is because of the stresses on the skin from movement, the weight of the breasts, and exposure to UV damage.4
Cleavage wrinkles are deep, vertical creases that appear as the skin becomes older and thinner. There are various physical causes for them appearing more prominent. These include hours spent sleeping on one’s side, where gravity forces the top breast to droop further past the body’s midline than it should, and by wearing sports and push-up bras, which push the breasts together, worsening the appearance of lines and wrinkles, similar to those that occur on the face due to muscular tension exerted on the skin.5
The skin covering the chest area tends to get a lot of sun exposure too, and is thinner than that on the arms and legs, making it extremely vulnerable to UV damage,6 resulting in sun spots, and other signs of ageing. Once the collagen in the skin breaks down from age and sun exposure, those wrinkles tend to linger and, thanks to gravity, the generously endowed, whether naturally or surgically, tend to be more affected.7 Throw in the volume loss that occurs naturally with ageing, as well as pollution, smoking and repeated rapid weight changes; and the chest quickly loses its youthful appearance.
As a result of hormonal changes relating to the menopause and oestrogen deficiency, women in their 40s and 50s are also more prone to ageing in this area. These changes result in an accelerated breakdown of collagen and elastin, leading to skin thinning, dryness and other negative changes referred to as ‘solar elastosis’ or ‘dermatosis’.8
Another problem with older skin is the risk of increased inflammation. While usually not visible to the naked eye, photo-damaged and aged skin can be more reactive and prone to inflammation due to higher levels of inflammatory mediators (cytokines, prostaglandins and other immune mediated factors such as histamine release) and abnormal cellular activity immune system.9 Inflammation increases the production of harmful super-oxidative species (free radicals) and leads to increased cell damage, degradation of the skin matrix and rapid cell death, as well as an increase in the risk of neoplastic change.10 In fact, the décolletage condition, characterised by dilated vessels, red and brown spots, ruddiness, thin crepey skin, and the ‘bubble wrap’ appearance, is referred to as ‘poikiloderma’, derived from the neck condition ‘Poikiloderma of Civatte’.11 There are simple ways of preventing and improving the appearance of the décolletage. Many of the non-invasive procedures that make the face more youthful can also work well on the décolletage. As such, I have detailed some of the most common methods below, with information on how they should be used.
Peels are the backbone of good skincare and are often overlooked, yet they can do much to improve the quality of skin including tone, texture and elasticity for all skin types
The next stage of the treatment requires the practitioner to inject 50-60 small intra-dermal deposits of PRP,13 (this further stimulates stem cell activity in the skin and hypodermis adipose layer)14 into the décolletage. The skin will be red for approximately seven to ten days, and peeling will occur. The results improve over the next few months as the skin repairs and regenerates, and new collagen is formed. It is essential to advise patients to moisturise the treated area morning and night while the skin is healing. This reduces inflammation and damage to the skin through the skin cracking. While one treatment will see an improvement in texture, tone and tightness, a course of three treatments is advised – one to two months apart. It’s also important that patients use SPF50 on the treated area to protect against further sun damage. In our experience results can last beyond three years. Histological studies have shown that some of the effects of CO2 resurfacing are permanent.15
Hyaluronic acid: As the décolletage is an area of thin skin, I would advise using a hyaluronic acid based filler, which can be finely injected with greater control, to avoid the appearance of unsightly lumps and bumps. The hyaluronic acid should be injected into the skin with lots of tiny microinjections, aiming to replenish moisture and reduce the appearance of fine lines while plumping skin, without the risk of leaving bumps, caused by larger deposits of product. While treating the face with fillers might require a syringe or two, the décolletage could require as many as ten syringes over three sessions to achieve best results. This is because of the large surface area, and the need to minimise the risk of leaving a bumpy outcome. The action of injecting will also contribute to the skin remodeling, as with microneedling. Avoid using permanent fillers such as silicone, as well as any filler that is long lasting and may result in nodules, which can be difficult to manage. In our experience, the results from hyaluronic acid used in this way should last up to a year. The maintenance with good skin care and SPF protection will give even longer lasting results.
Poly-L-lactic acid (PLLA): Diluted PLLA should be administered sub-dermally in small injections, and then massaged into the décolletage. Three to five sessions, a month apart, are advised to get a result that will last up to four years.26 I would advise one maintenance treatment every 18 months in order to maintain the results, as involution of the effects starts about then.27
Botulinum toxin: Small doses of diluted botulinum toxin type-A, injected into the dermis 1 to 2cm apart, also have a smoothing effect on the décolletage. The mediation of this effect is unclear, but may relate to a relaxation of fibres or cells in the dermis, that may have some contractile function. This is a safe treatment with minimal risks, and results can last three to five months.
Non-ablative: A non-ablative radiofrequency skin tightening treatment can help tighten crinkly décolletage skin by stimulating collagen production. A conductive gel is applied to the décolletage, before the radiofrequency device delivers constant gradual energy to the skin, causing heat to build up where the skin and fat layers meet.
The increasing heat modifies the collagen bundles deep inside the skin causing them to contract, thus stimulating the production of new collagen over time. Most patients notice a tightening of the skin after one treatment, with ongoing improvements over the following four to six months as new collagen is formed.28,29 For best results a course of six treatments, two weeks apart, is recommended. The procedure should give lasting effects with one maintenance treatment a month. This gives rise to the best results through tissue remodeling.30
Ablative: Ablative radiofrequency devices, with coated or uncoated pins that create holes in the skin and tissue coagulation, can also be very effective. We do, however, have to be careful not to use very high-energy settings, as the skin in this area is very thin and prone to scarring. Three sessions, six weeks apart with annual maintenance are advised.31
The décolletage is a greatly ignored area of the body when it comes to anti- ageing and protection. It is a vulnerable area predisposed to photo- ageing and the effects of shearing forces, particularly in women who have very few hair follicles on their chests
In addition to the treatments listed above, I advocate the use of skincare packed with antioxidants such as peptides and vitamins to protect, repair and hydrate the décolletage. Vitamin C is a fantastic ingredient for treating this area as it builds collagen (which plumps the skin) and treats, as well as helps prevent, pigmentation.40 Products containing vitamin A are also suitable for use on the décolletage as they will help repair sun damage.41 In conclusion, the décolletage is a greatly ignored area of the body when it comes to anti-ageing and protection. It is a vulnerable area predisposed to photo-ageing and the effects of shearing forces, particularly in women who have very few hair follicles on their chests. The treatments that work on the face also have benefits on the décolletage, however the skin here is slower to heal, and easier to damage. The practice of preparation with skin care including retinoids and vitamin C, with, or without hydroquinone (in Fitzpatrick skin types IV-VI) is always prudent. Experience has taught us that combining treatments can help us to attain better results, with fewer risks and side effects. My advice to practitioners is to use the treatments they already use on the face, but with greater care on the décolletage. There is no right or wrong, as long as we ensure patient safety and effectiveness in achieving expected results. This puts great emphasis on managing patient expectations, and the informed consenting process. All of this starts with the consultation and listening to the patients.
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