Treating the Décolletage

By Dr Aamer Khan / 01 Sep 2015

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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.⁴Cleavage 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.⁵The 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’.⁸Another 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.

Combined CO2 resurfacing and PRP décolletage treatment

This 60-minute treatment uses fractional CO2 laser combined with Platelet Rich Plasma (PRP) injections to treat the décolletage. The practitioner should apply topical anesthetic to the entire cleavage area, before using a fractional CO2 laser to encourage new collagen to form. The energy delivered has to be relatively low as the skin in this area is thin, reactive and prone to laser damage. The laser should also be adjusted to the patient’s skin type, as skins of colour can be more reactive, and prone to post-inflammatory hyperpigmentation.¹²

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

Biomimetic mesotherapy

This 20-minute procedure will aim to treat sun-induced wrinkles with no significant downtime. Biomimetic mesotherapy stimulates the mesoderm (mid-dermis).^16,17 First the décolletage is cleansed, then a series of injections containing active ingredients including hyaluronic acid, retinols and peptides, which aim to help boost the collagen and elastin, are placed on the décolletage. The treatment aims to help rejuvenate skin and soften fine lines and wrinkles. Patients should see smoother skin within a couple of weeks, but for best results, a course of three weekly sessions is recommended. Side effects include small bumps and pinprick bleeding, which settles within six to twelve hours.
The limited injury from the mesotherapy starts a healing response in the skin, with increased cellular activity and collagen stimulation. The ‘biomimetic peptides’ mimic growth factors and stimulate the repair activity even more.

Chemical peels

In my opinion, 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. A course of glycolic peels is particularly good for smoothing fine lines on the décolletage, with minimal downtime. Glycolic peels are also known as ‘cellular peels’, and work at the cellular level, causing cellular shock, and cells to shed, rather than sheets of skin.¹⁸ The peeling process is slower, so often requires six treatments. It is important to note that the skin has to be pretreated with AHA skincare to condition the skin prior to these peels, for at least two weeks, this helps to condition the skin and reduces the risks of skin damage.¹⁹The glycolic solution should be prepared to suit the patient’s particular skin type and then brushed over the décolletage and left on for approximately ten minutes. Following this, the solution is rinsed off with water, and a moisturising lotion and sun block is applied. A course of six peels, one a week, will produce best results. This is because each peel can penetrate a little deeper, addressing more fine lines and discoloration. This treatment will also encourage dermal cellular activity,²⁰ thereby giving the skin a plumper and younger appearance. Results should last up to a year and, in my clinic, we usually advise patients to continue to use skincare that contains AHA for maintenance. For best ongoing results we advise one peel every three months. Stronger chemical peels that cause cellular necrosis and shedding carry a higher risk,²¹ but can be useful in more severely damaged skin. Newer formulations of combined chemicals are proving safer and effective. Skin conditioning is recommended, and maintenance is the mainstay of lasting results.²²

Microneedling

As the microneedle roller is rolled over the skin, it creates pin- point punctures in the dermis – the majority of which temporarily push pores open. This reaction is perceived by the body as damage, thus activating a wound healing response to regenerate the skin and boost collagen levels. As a result, thin skin thickens and fine lines, scars, and uneven skin tone are targeted.²³ The skin is then cleansed, a peptide serum is usually massaged in and the roller is gently rolled over the skin several times, allowing the peptide serum to penetrate into the skins layers. Antioxidant serums are then applied.
There may be a temporary reddening of the skin for an hour after treatment, and a course of six treatments once every four- six weeks is recommended. The natural healing process lasts for several months in which time skin will carry on improving.²⁴ Maintenance is then advised every three to six months, depending on the age and condition of the skin. Improved results can be gained when this technique is combined with red light and IPL treatments.²⁵

Dermal filler injections and botulinum toxin treatment

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.

Radiofrequency

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

Photodynamic therapy (PDT)

PDT is an established method for treating some non-melanoma forms of skin cancer, while also having the added benefits of being a highly effective treatment for rejuvenating the skin and treating pigmentation and sun-damaged chests.^32,33 It’s a simple procedure but time consuming, and can be painful for the patient. To begin, an exfoliating mask is used to slough off dead skin cells and prepare the skin for treatment. A cream containing a light- sensitising chemical, 5-aminolaevulinic acid (ALA), is applied to the sun-damaged skin. The treated area will then be covered for up to three hours to allow the cream to penetrate into the sun- damaged skin cells. The damaged cells, through active amino acid uptake channels, preferentially take up the 5-ALA, which makes the damaged skin cells very sensitive to the PDT light.^34,35 A red LED laser is then used to target the photosensitised cells for ten minutes. The light will target the damaged cells, but not the normal cells. The body then repairs and replaces the damaged cells with new healthy skin cells. After the treatment, patients may notice some redness, blistering, peeling and milia formation for up to two weeks. Advise patients to keep the treated area covered and moisturised for 36 hours.

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

Intense Pulsed Light (IPL)

Despite the latest state of the art treatments, there’s something to be said about the tried and tested treatments such as IPL. The light-based device is used to reduce discoloration, sun damage, and broken capillaries. IPL is also successfully used for treating age spots as it targets melanin in the skin and, with four to six treatments, a significant improvement can be seen.36
There is little downtime, though treated skin may be red for a few hours, and the pigmented areas appear darker before scaling off. This treatment targets both pigmented areas and the vascular elements of the photodamaged skin.
In practice, IPL is ‘fired’ at the area to be treated. Photo-filters are used at specific wavelengths to target a specific pigment. This releases low levels of energy into the skin, which then stimulates regeneration of the cells, and also boosts collagen so skin becomes tighter and plumper. High-energy absorption into the target pigment causes photo-coagulation of the tissues, which are then repaired and replaced by the body. Lower levels of energy released also have an anti-inflammatory effect on the healthy tissues. Patients often report that the treatment feels like an elastic band is being pinged against the skin, especially in the areas where the target pigment is at its greatest. A few days post treatment, the treated areas become darker before they fade. Patients may need up to six treatments and the results are likely to last up to 18 months. I recommend patients undergo this treatment in the autumn or winter when they will not be exposed to a sunny climate, as treated areas can burn or become darker when exposed to UV light. As always, I advise my patients use an SPF50 to protect their skin following treatment.

Polydioxanone (PDO) sutures and dermaroller in combination

The latest weapon in our fight against the aged and damaged décolletage is the use of PDO sutures inserted sub-dermally to form a structural matrix, followed by rolling a 3mm dermaroller over the surface and PRP application.³⁷ This treatment is performed under topical local anaesthesia. 30G Knotless PDO sutures are positioned in the hypodermis in a criss- cross fashion to form a matrix. As they dissolve, they stimulate cellular activity and collagen production. The sutures provide the extra-cellular matrix upon which the collagen is structured and laid down. A 3mm dermaroller is used to produce microneedling trauma to the tissues, in order to increase the cellular activity and healing.^38,39 This combined treatment can give excellent skin rejuvenation, which, judging by my experience, can last for more than two years. In my clinic, we are seeing excellent results with this technique. It is also helpful in improving the appearance of stretch marks around the décolletage and breasts.

Conclusion

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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