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Part six in our series of articles, focuses on the evaluation and aesthetic management of the neck and jowl regions. The main authors, Dr. Emil Bisaccia and Dr. Dwight A. Scarborough, are authors of the textbook, The Columbia Manual of Dermatologic Cosmetic Surgery.
n youth, the jaw line at the inferior margin of the lower face is sharp and uninterrupted, forming the desirable V shape of the face during its prime years of youth. With the sagging of the cheek skin, the U configuration of the aging face is noted, sometimes as early as in the fourth decade, and the angle between the mandible and the neck loses its acuity and becomes blunted.
From the seventh decade onward, the jowls may protrude even more. At this point the skin laxity is severe, allowing the jowls to extend into the neck area below the mandible.1
Analyzing the Neck
The shape, contour and proportion of the neck in relation to the face play an essential role in devising rejuvenation strategies for the aging face. The neck extends superiorly to the chin and inferiorly to the sternal notch. The thyroid cartilage and the hyoid bone are two of its landmarks. The most important structure responsible for the appearance of the aging neck is the platysma muscle, which originates from the pectoralis fascia and extends upward in the shape of a sheet, where it inserts medially at the mandible. It forms the lower face-and-neck superficial musculoaponeurotic system (SMAS) plane in conjunction with the superficial parotid gland fascia, the risorius muscle and the depressor angulis oris muscle inserting below the zygomatic arch.
There are a variety of platysma muscle variants that directly affect the aging neck. If the platysma muscle divides in the midline, early “turkey gobbler” formation is expected. On the other hand, if the platysma muscle is interlaced in the midline, then the effects of aging aren’t seen until later in life.
The cervicomental angle is created through the attachment of the platysma muscle to the hyoid bone. A youthful angle measures between 105 and 120 degrees. Another criterion for a youthful neck is a submental-sternocleiodomastoid angle of 90 degrees.
The neck ages slowly and gradually, following the medial to inferior vectors of aging and the gravitational force from superior to inferior.
During the 20s, fine horizontal lines appear; however, the youthful contour of the neck is maintained.
During the 30s, mild skin laxity begins to appear, leading to progressive blunting of both the cervicomental and submandibular-sternocleidomastoid angle. Subtle platysmal bands begin to show, and the horizontal lines increase in depth and number. The submental triangle loses its firmness and appears rounded rather than flat.
Thick platysmal bands, subplatysmal and submental fat pads, and moderate jowl formation are seen during the 40s. The chin pad descends, and skin laxity is moderate.
From the 50s onward, the neck loses its contour. Thick, hypertrophied platysmal bands and severe skin laxity with deep horizontal folds as well as complete chin ptosis due to loss of bone and deep tissue support dominate the appearance of the neck.1 The loss of bone volume and soft tissue support in conjunction with the appearance of the jowl obscure the line of the body of the mandible.2 The aging of the skin may be accentuated even further in response to photodamage, evident in the signs of dyschromia and poikiloderma of Civatte.
Now, let’s discuss the different approaches available to recover a youthful look for the neck and jowl.
Neck and Jowl Liposuction
Neck and jowl liposculpture is a simple procedure done either separately or in combination with other cosmetic procedures. Fat located in the jowl is usually removed through a very small incision just in front of the earlobe. Here, a special fat extractor is placed beneath the skin and fat is removed through low-power suction. For fat accumulations in the neck and chin area, a very small incision should be made just below the chin to extract fat from the entire neck area.3
Before
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After
|  | | Before (top) and after (bottom) pictures of a patient who underwent neck and jowl liposuction. Liposuction has simplified the
earlier, tedious open procedures and allowed for closed intervention with limited side effects. Photos courtesy of Omar Torres, M.D.
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In performing a liposuction of the neck and jowl, it’s important that the cannula stays above the SMAS layer and its neck extension (the platysma) to avoid damage to important anatomic structures, such as the facial nerves and blood vessels. The facial artery and vein and branches of the facial nerve, more specifically, its marginal mandibular nerve branch, are at highest risk for injury. The marginal mandibular nerve runs underneath the SMAS along the mandible and is most vulnerable over the jowl liposuction area, where the SMAS is thinnest, at a 2-cm radius drawn over the midmandible 2 cm posterior to the oral commissure.4
These procedures may be done under local anesthesia or with light sedation, depending on the extent of surgery. After the operative procedure, apply small special tapes and have the patient wear a facial elastic garment for about 1 week. Liposuction has simplified the earlier, tedious open procedures and allowed for closed intervention with limited side effects, especially in the face and neck. We found that facial and neck liposuction with the use of small instruments — cannulae of 2.1-mm to 4-mm gauge and
10-ml or 60-ml syringe — further reduces complications and achieves excellent results.3 (See photos above.)
Intense Pulsed Light (IPL)
IPL is a non-ablative, non-laser light source in the visible spectrum that emits light at variable pulse durations, intervals and wavelengths. It has been shown to stimulate collagen production and cause proliferation of the epidermis. Skin texture, telangiectasias and mottled pigmentation have been shown to improve after several treatments. The neck has been reported to respond less favorably than the face. Caution must be used when even light pigment is present. A conservative approach is recommended since adverse effects associated with this type of treatment include hypopigmentation, temporary crusting, erythema and purpura.5
Jessner, TCA 25% and Glycolic Chemical Peels
Jessner, TCA 25% and glycolic chemical peels have yielded successful results in the rejuvenation of the neck area when treating dyschromia, lentigenes, post-inflammatory hyperpigmentation and early rhytids.
Prior to a chemical peel, and at the physician’s request, the patient may undergo a 1- to 2-week preconditioning program that includes daily skin exfoliation and the application of glycolic lotions and/or retinoic acid so as to debride the stratum corneum, and allow increased penetration of the peeling agents and a more rapid re-epithelialization.6 After this period of time, the skin will experience minor peels and attain a rosy red color.
On the day of the procedure, have the patient wash his or her skin with soap and water or alcohol so as to rid it from sebaceous oils. Care must be taken if acetone is used to defat the skin since the depth of the chemical peel may be difficult to control. The depth of the peel may be judged by color, time and palpation. In a superficial peel, the skin is expected to have a diffusely pink/white-frosted appearance that reblanches in 10 to 15 minutes; palpation reveals a mild boggy edema.
After the peel, the skin has to be protected with a layer of bland emollient and/or antibiotic ointment, and the patient must wear sunscreen on a daily basis.
Microdermabrasion
Microdermabrasion is a safe procedure to address poikiloderma of Civatte on the neck as well as pigment irregularities of the face. It’s a bloodless and noninvasive rejuvenation technique that consists of exfoliating the skin with aluminum oxide crystals and/or sodium chloride salt projected through a tube from a reservoir attached to a reservoir that contains an aspirator. The depth of the peel depends on the projectile pressure and intensity of the aspirator. In the case of the neck, a low-pressure setting should be selected.
Two days prior to the procedure, urge patients to discontinue the use of products containing alpha hydroxy acids and retinoids. For best results, microdermabrasion treatments should be performed at 1- to 3-week intervals. Microdermabrasion is an effective solution for younger looking skin and its advantages are little or no discomfort, no anesthesia, minimal or no recuperation time, immediate return to normal activities and suitability for all skin types.7
Botox
Another fascinating use of botulinum toxin type A (Botox) is in the rejuvenation of the neck. Botox relaxes the horizontal lines of the neck and the platysmal bands, attaining a more youthful look of the neck altogether. Platysmal bands are caused by SMAS attachments to the neck.
Before
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After
|  | | Before (top) and after (bottom) platysmal band treatment with botulinum toxin type A. Botox is a viable and effective primary and secondary therapy for patients whose neck aging is owed to platysmal muscle hypertrophy. Photos courtesy of Omar Torres, M.D.
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The areas to be treated are prepped and the platysmal bands are grasped and injected. Typically, each vertical band is injected at three different sites approximately 1 cm to 1.5 cm apart with 5 units of Botox. Approximately 1 to 2 units can be injected intradermally at 1-cm intervals to soften horizontal lines.8 The treated areas are then iced for 5 to10 minutes (see photos showing results above).
Slight redness and mild bruising are not uncommon; however, the avoidance of aspirin and antiplatelet medication for 2 weeks prior to treatment tends to decrease bruising. Carruthers and Carruthers recommended massaging the neck gently after the procedure to reduce the risk of bruising as well.9
You should be aware of the presence of deglutition muscles deep within the platysma and the deep venous perforators, particularly in the lateral neck and the larynx to minimize complications. In order to avoid unwanted side effects, such as dyspnea, dysphagia and neck weakness, no more than 30 units should be injected in any one cervical area.9
The use of Botox for the temporary treatment of platysmal bands is a viable and effective primary and secondary therapy for patients whose neck aging is owed to platysmal muscle hypertrophy. Lastly, Botox can also be beneficial for patients who exhibit noticeable platysmal banding after undergoing a neck and jowl liposuction.10
Choosing a Technique
There are numerous alternatives for individuals seeking a more youthful look in the areas of the neck and jowl. The range of rejuvenation techniques for both neck and jowl, as considered in this article, give you the opportunity to make an educated decision on the procedure that will best suit the needs and particularities of each patient. |
THE MANY FACES OF ROSACEA
CME Critical Reviews of Clinical Data:
Fall Clinical Dermatology 2007
Acne Case Reports
2007 ADVANCES IN COSMETIC &
MEDICAL DERMATOLOGY
“MAUI DERM” CONFERENCE
July 2007 CME Supplement
2007 Winter Dermatology Conference Hawaii®
2006 4th Annual Fall Conference Supplemental Proceedings