Mr Marc Pacifico outlines treatment options for addressing the submental area and shares a successful case study
The submental area can be one of the most challenging areas of the head and neck to treat. This relates to both the underlying anatomy as well as various pre-existing factors; the principle being skin quality, but also including environmental insults (such as smoking and sun exposure), background genetic make-up and history of weight fluctuations. A typical patient presenting to clinic will either complain of a ‘double chin’ or a ‘turkey neck’, which in effect gives a clue to whether their problem is principally related to excess fat or skin, respectively. In some cases, there may be a combination of the two. In this overview, I look at assessment and treatment options for the submental area.
If the underlying issue relates to skin excess, usually as a result of ageing but sometimes associated with weight loss, I believe that surgery remains the gold standard in the form of a lower face/neck lift, with or without the addition of further direct access to the submental area via a submental incision to plicate the platysma muscle. Surgery also retains a strong role in addressing fat deposition in this area and has the advantage of allowing access to both deep and superficial fat compartments. Broadly speaking, the fat can be located superficially or deep to platysma. Superficial fat can easily be accessed using liposuction, as well as by a variety of non-surgical technologies, which I discuss in more detail below. Deep fat is more challenging to remove and can only be addressed via surgical means.
I would say that over the last 10 years, non-surgical technologies have been developed to address submental fat deposition through a variety of means. The non-surgical approaches offer a strategy to address pre-platysmal (subcutaneous) fat rather than sub-platysmal deep fat.1 They each offer potential advantages with varying side effects and are becoming an increasingly attractive alternative to surgery for many patients. Before discussing the various options available to patients, it is vital to ensure that several key steps are taken during the assessment stage to adequately assess a patient for suitability for non-surgical submental approaches, as well as to determine whether surgery might be the more suitable option.
First of all, the quality of the skin needs to be determined to assess whether there is a presence of skin excess or whether the morphology of the area is primarily due to fat deposition. If skin excess is present, this will have variable success in contraction once pre-platysmal fat is reduced. As a rule, the older and less elastic the skin is, the less predictable and less likely the skin is to retract. The risk in this situation is that fat reduction without skin removal leaves further excess, ptotic skin; much to the patient’s chagrin. In my experience, the best result with isolated fat reduction approaches are generally seen in younger, better quality skin that is generally thicker, non-sun damaged with more elasticity. If it is hard to determine whether the submental appearance is due to skin or fat, a good technique is to assess and compare the patient in lateral view standing and laying (Figure 1 and 2). If the patient retains submental fullness when laying supine, it indicates there is fat deposition in the area. If, however, the patient’s shape is significantly improved when supine with loss of submental fullness, then fat is not the underlying cause, but rather skin and platysmal laxity.
It is key to determine whether submental fullness is a result of pre-platysmal fat, or deep sub-platysmal fat (or a combination of the two). Isolated fat reduction techniques will not address sub-platysmal fat that resides between the platysma and floor of mouth. This can only be accessed surgically. To determine the location of the fat, a tip is to pinch the patient’s submental area and ensure a good hold of the soft tissue (Figure 3 and 4). Ask the patient to swallow. The tissue remaining in your pinch is subcutaneous/pre-platysmal. Any tissue that has been pulled away from between your pinch is sub-platysmal. It can be surprising in some cases how much of the submental fullness is actually sub-platysmal.
Recently, novel technologies have gained traction to address this area non-surgically. There is an increasing desire to obtain a degree of improvement in the submental area without resorting to surgery, whilst patients are prepared to accept a more modest improvement with a non-surgical approach.
Rodrigo Neira et al. led initial studies1,2 providing evidence that the application of laser therapy at 635 nm with output intensity between 7 and 20 mw consistently induces the formation of a transitory pore within the membrane of adipocytes, provoking their collapse.2,3 The low-level laser therapy emulsified fat and encouraged its release from cells. This development initially led to it being used as an adjunct to surgical liposuction.2 Subsequently, Jackson et al. investigated using low-level laser as an independent isolated means of achieving fat reduction, without the use of additional liposuction.3,4 In the randomised control study, they demonstrated for the first time that the effects of low-level laser significantly achieved fat reduction. The same group reported an overall reduction in both triglyceride and total cholesterol levels following two weeks of laser therapy.5,6 Very few side effects of this treatment have been noticed, aside from localised redness, and a transient swelling of regional nodes, which is associated with the fat excretion.
Since the ‘popsicle panniculitis’ observations, when buccal fat was noted to reduce in volume with cold exposure from ice-lolly sucking,8 a variety of cryolipolysis devices have been developed. This relies on controlled cold exposure to affect a gradual reduction of the subcutaneous fat layer using natural thermal diffusion, without damage to other tissues. Studies have demonstrated a 2-3.7 mm fat layer reduction, with no rise in serum lipid levels or derangement of liver function tests.7 Adverse effects include self-limiting effects such as erythema, numbness and sensitivity, and there have also been reports of paradoxical adipocyte hyperplasia requiring treatment with surgical liposuction.
Using low dose formulations of a purified synthetic version of deoxycholic acid, focal adipocytolysis can be achieved, with the surround soft tissue being largely unaffected.8 A study held by Rotunda Am et al. using a combination of cell cultures and porcine skin treated with phosphatidylcholine demonstrated a significant loss of cell viability, cell membrane lysis, and disruption of fat.9 In my experience, these require a number of treatments (often two to three, but sometimes upwards of five) at one-month intervals. Adverse reactions tend to be localised and temporary, and can include injection site oedema, haematoma, numbness and, rarely, transient palsy to the marginal mandibular nerve.
Radiofrequency submental fat reduction relies on the deep heating of adipose tissue to stimulate destruction of adipocytes. A consensus statement published in 201710 suggested that subdermal radiofrequency treatment in the submental area was an effective means for disrupting fat volume and skin tightening. It also offered the potential for skin tightening of the face, neck, and jawline. However, in a similar way to most non-surgical approaches, the authors recognise that better results can be achieved in those with better skin quality and a mild to moderate degree of fat deposition. As with most of the other non-surgical options, most side effects are localised and self-limiting, such as erythema, pain, oedema and vesicle formation.
A 22-year old patient with underlying polycystic ovaries, presented in clinic complaining of submental fullness, which is not uncommon in those with this condition.11 It was something that she was particularly concerned with and as a result her confidence and self-esteem were very low. Examination revealed a significant area of pre-platysmal fat and good quality overlying skin. She underwent four treatments using the Strawberry Lift device, which uses low-level laser therapy, at two-week intervals. Over that time period she didn’t lose weight from the rest of her body, as she was just trying to focus on this area. The pictures below demonstrate her lateral view before undergoing any treatment, and then eight weeks after completing the course of four treatments. The patient was very pleased with the results and will be reassessed six months post treatment to see if any further treatments are indicated.
An accurate assessment is imperative to ensure that the treatment modality of choice is appropriate for the patient with concerns of their submental area. A non-surgical treatment being used to try to improve sub-platysmal fat will only lead to disappointment that could have been avoided. Whilst I believe that surgery remains the gold standard, the range of potential non-surgical treatments to address submental pre-platysmal fat is increasing, with few side effects or complications, and is becoming increasingly desirable to the patient population, partly due to the low to no downtime as well as being more cost effective.
Disclosure: Mr Marc Pacifico is a KOL for Laser Lipo, manufacturer of the Strawberry Lift.
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