Day 3: Highlights

Saturday, February 11, 2017

Anatomy Considerations for the Neck

Z. Paul Lorenc, MD, FACS

There are three aspects of the neck that are of particular concern in non-surgical rejuvenation: the platysma muscle, pre/sub platysmal fat, and the Marginal Mandibular nerve. 

In the aging neck, loss of firmness and jawline definition can be due to weakening of retaining septum (i.e. mandibular septum), loss of bony support, loss of skin tone/texture, sagging of skin and subcutaneous fat, or due to changes in the platysmal muscle support. Ideal neck parameters, which are not usually seen in patients, include a distinct mandibular border, sub-hyoid depression, visible thyroid cartilage, visible anterior border of the Sternocleidomastoid muscle, and a cervicomental angle of 105-120 degrees. 

The platysma is a very broad muscle with its origin from the subcutaneous layer and fascia covering the greater pectoral and deltoid muscles at the level of the 1st or 2nd rib, and the platysma inserts on the Mandible, the Risorius muscle, and the platysma on the opposite side.

When treating the platysma with toxins, better cosmetic results may be achieved with treating the whole platysma, including the lateral platysmal and the platysma at the mandibular border, instead of just the medial platysma.

Most of the platysmal fat is located in the pre-platysmal space (2/3 of the fat is anterior to the platysma and 1/3 of the the fat is posterior to the platysma). Dr. Lorenc uses the Thermi RF system to melt fat and shrink the skin. 

It is critical to locate the Marginal Mandibular Nerve when using non-invasive Radiofrequency, and when using KYBELLA (an injectable adipo cytolytic). Damage to the Marginal Mandibular Nerve leads to ineffective smiling as one side of the mouth remains elevated as the Depressor angularis oris and the Depressor labii inferioris muscles are compromised.

The neck is a complex anatomical area, and aging of the neck is multifactorial. Therefore, a multifactorial treatment plan is needed to address skin, fat, and muscle.

Fat Reduction and Skin Tightening

David Goldberg, MD, JD

There are many device options available for neck and submental rejuvenation including Radiofrequency, Injectable Radiofrequency, Micro-focused Ultrasound, Cryolipolysis, and Dissolvable Sutures. 

Radiofrequency is best utilized to tighten skin, as it has minimal fat reduction capabilities. Different types of probes exhibit their effects at different depths. Bipolar has more superficial effects while Monopolar and Unipolar affect the skin at deeper depths.

Injectable Radiofrequency devices can help tighten skin and reduce fat. The temperature can be measured on the outside and inside the skin. Skin smoothing occurs at a temperature of 42C and shrinking of fibrous septae occurs at temperatures of 55-66C. 

Micro-focused Ultrasound is employed for tightening skin. This is the only approach that is FDA-approved to both tighten and lift Submental and Neck skin. The transducers allow for precise heating at 3 focal levels, and use of these devices are safe in all skin types. An additional advantage of Micro-focused Ultrasound possesses is that improvement can be seen after a single treatment.

Cryolipolysis devices (CoolMini) are designed for Submental fat and are ideal for smaller bulges. These devices freeze the fat that results in a gelatinous look to the skin at first, but this will then melt away. 

Dissolving Sutures have sutures and cones made of Poly (L-lactic-co-glycolic acid) or Poly (L-lactic acid). These products have bidirectional sutures, and their smooth cones provide anchor points in the subcutaneous tissues. In addition to re-contouring the skin and improving wrinkles, there is a biostimulatory effect.

With all these options, combination therapy should not be excluded, such as use of a Suspension Suture and Injectable Radiofrequency.

Injectable Fat Reduction

Joel Cohen, MD

KYBELLA is a synthetic version of deoxycholic acid that is used in the contouring and reduction of Submental Fat. This drug is the only FDA-approved deoxycholase submental injectable. KYBELLA is injected into the pre-platysmal fat and works via lysis of the adipocytes (adipo cytolysis), but it does recruit some fibroblasts.

Objective measures in recent research studies included MRI scans to evaluate Submental volume and thickness, which showed improvement. After only one treatment, there was improvement from using KYBELLA as compared to placebo.

Adverse events, including edema, swelling, bruising, pain, numbness, erythema, and induration, were mild 82% percent of the time. Some bruising is attributed to needle trauma. The incidences of edema, pain, and numbness declined after the first treatment session.

Follow-up studies have shown a persistent effect – at 3 years and 5 years, there is a consistency of response. Patients can receive up to six treatments, with an average of 4.2 treatments, but most patients are happy with results after 2-3 treatments. 

Ulceration has been described in a few cases, and there have been a few incidences in men of alopecia in the area of injection. It is important not to compound KYBELLA, as it may lead to Granuloma annulare. 

Neck: Wrinkling and Poikiloderma

Glynis Ablon, MD

Conditions and symptoms in the neck needing treatment include poikiloderma, wrinkling, neck bands, skin laxity, and excess submental fat deposits. There are numerous treatment options – topical agents, chemical agents, neuromodulators, laser and light sources, fillers, and minimally-invasive procedures. 

Topical agents primarily address the overall color of the neck. When utilizing chemical agents, it is important to remember that the neck is very different than other parts of the body, and there are not a lot of sebaceous glands in the neck. Dr. Ablon recommends using a low concentration when using chemical agents (20% or less of Trichloroacetic acid [TCA]). Neuromodulators can be used to treat the jaw line and neck bands.

Lasers used for treating the neck are grouped into two categories – Non-Invasive, such as Intense Pulsed Light (IPL), and Minimally-Invasive, such as Erbium. Non-Invasive Lasers can be used to treat poikiloderma, vessels, lentigenes, and actinic damage. Due to the presence of the filter, IPL utilizes multiple wavelengths of light. Most patients require six sessions, with additional treatments to achieve collagen tightening. At the histopathological level, use of IPL results in a more homogenous melanin distribution, a higher number of fibroblasts, higher number non-fragmented elastic fibers, and higher density and thickness collagen bundles. It is important to discuss the complications associated with IPL with patients. Dr. Ablon recommends providing to patients an informational flyer that reviews what can occur and what to do. True complications of IPL are thermal burns, alterations in pigment, and infection, while perceived complications include scabbing and crusting, prolonged erythema, and bruising. It should be noted that the treated area may darken if the patient has a lot of lentigenes. 

Minimally-invasive lasers, such as Erbium lasers, vary in their depth of treatment. Erbium lasers can be used in multiple or single sessions, but fractionating treatment does lead to less downtime. The three types of Erbium lasers are Superficial, Fractional, and Fully Ablative, which differ in depth and effects. Superficial Erbium is microlaser microneedling and treats the epidermis. Fractional Erbium is used for collagen induction. Fully Ablative Erbium allows for deep dermal remodeling and collagen induction. Topical anesthetic is typically necessary – remember that the neck is a sensitive area, so it is preferred to fractionate and not ablate with Erbium lasers. 

When treating the neck, combination therapy is best. It is important to address all the issues the patient has with the neck and the global picture, but this needs to be done in a gentle way. There are lots of treatments available, but it does take time. 

Advanced Live Patient Certification Workshop: Absorbable Lifting Sutures

Mark Nestor, MD, PhD

In the normal aging process of the face the triangle reverses. There is also fat loss and redistribution which manifests as infraorbital hollows and deepening of facial lines and this progresses over time. The new absorbable lifting sutures were developed in Europe and have advantages over previously available barbed sutures in that they are completely absorbable suture material and contain hand-tied cones instead of barbs. The absorbable lifting sutures are comprised of poly-glycolide and L-lactide (PLGA) and poly-L-lactic acid (PLLA).

Absorbable lifting suture procedures are minimally invasive and give immediate lift and contribute to lon-term collagen stimulation. The ideal candidate has a lower BMI and strong underlying bone projections. The potential adverse events are similar to those with any surgical procedure, as well as dimpling and bunching of the skin immediately after the procedure. Occasionally the suture will break however the session panelists shared that this is very rare. Improvement in facial contour and facial volume continues to improve up to 1 year after treatment, according to one study. 

Panelist Dr. Susan Weinkle explained that the goal of the absorbable lifting suture procedure is to reposition and re-drape the skin. Results in the right candidate will be impressive, but they will not be similar to those of a facelift. Also, the appearance of the face immediately after the procedure will not be the final result because over time the collagen production will continue to improve the contour of the face. Dr. Weinkle also shared that the backbone material in the absorbable lifting sutures stimulates fibroblasts.  

A live patient demonstration followed the discussion and Dr. Winkle demonstrated preparation for the procedure. She encourages us to set appropriate expectations for the patient, and to start out with the eight cone suture material as this is the most commonly used in her experience. Before marking the patient, it is important to degrease and cleanse the face of the patient. Dr. Weinkle demonstrated using alcohol followed by hypochlorous acid spray.  She then marked the patient using vectors to reposition and re-drape the facial skin. Dr. Weinkle stated that in her own practice she takes pictures of the patient after marking for the records and to visualize the original plan if the patient returns for additional treatment.  

Dr. Weinkle then used an 18 G needle to make the opening for the absorbable sutures. This area as well as the exit point were anesthetized with 1% lidocaine with epinephrine prior to the procedure. She encourages us not to anesthetize the subcutaneous tract because it should be painless, and if the patient experiences pain it indicates the needle may be in the wrong plane. The absorbable sutures come attached to 2 needles, and Dr. Weinkle reminded the audience to pull near the cones and not from the needle when placing the sutures. The panelists reviewing the post-operative instructions, such as dietary restrictions on chewing and opening the mouth widely. Also, there may be future uses for the absorbable lifting sutures including treatment in the brows and neck. Facial asymmetry may also be corrected by placing different numbers of suture material on each side of the face.