CLINICAL ANATOMY/REGIONAL APPROACHES

Décolletage: Regional Approaches with

Injectable Fillers
Monique Vanaman, MD Background : Patients increasingly request rejuvenation of the aging and pho-
Sabrina Guillen Fabi, MD, todamaged décolletage. Rhytides in this area can be addressed with inject-
FAAD, FAACS ables such as poly-l-lactic acid and hyaluronic acid products and energy-based
Chicago, Ill.; and San Diego, Calif.
devices, such as fractionated ablative and nonablative lasers and microfocused
ultrasound with visualization.
Methods: This article will review the anatomy of the chest wall as it pertains to
injectables that can be utilized in this area and injection technique. A review
of the literature and the authors’ experience will be discussed.
Conclusion: Cosmetic injectables can be utilized safely and effectively to im-
prove the appearance of rhytides on the décolletage.  (Plast. Reconstr. Surg.
136: 276S, 2015.)

T EVALUATION
he cumulative effect of intrinsic aging and
chronic environmental exposures, such as
ultraviolet, infrared and visible light radia-
tion, and pollution, results in wrinkles, dyschro-
mia, atrophy, telangiectasias, laxity, and roughness
of sun-exposed skin. As patients increasingly
achieve a younger and more refreshed appear-
ance through facial rejuvenation procedures,
they are often left with an abrupt contrast between
their facial and nonfacial skin such as the neck
and chest (décolletage). Patients are increasingly
aware of photoaging of the décolletage, resulting
in frequent requests for cosmetic enhancement
of this area.
There are many modalities that can be uti-
lized alone or in combination for the rejuvena-
tion of the décolletage, including injectables,
neurotoxins, chemical peels, sclerotherapy, pho-
todynamic therapy, intense pulsed light, micro-
focused ultrasound with visualization (MFU-V),
q-switched lasers, nonablative fractionated lasers,
and ablative fractionated lasers. This article
focuses on the use of fillers to address rhytides
of the décolletage, with a review of the pertinent
anatomy, biology, plane of injection, and injec-
tion technique to be considered when perform-
ing these procedures.
The availability of wrinkle scales in aesthetic
medicine has advanced the field by providing an
objective, validated tool for evaluating patients
and treatment outcomes. The Fabi-Bolton Chest
Wrinkle Scale was developed as a 5-point scale
that grades chest wrinkle severity from grade 1 to
grade 5.1 The Fabi-Bolton Chest Wrinkle Scale can
be used as a simple clinical device for objectively
grading rhytid severity preprocedurally and track-
ing patient outcomes.
In our practice, every patient is photographed
prior to treatment and at each follow-up visit.
Photographs are an invaluable tool for reviewing
and discussing treatment results with patients, as
once the treatment has been performed, patients
often cannot accurately recall their preprocedural
appearance.
Disclosure: Dr. Fabi serves as a trainer and is on the
speakers’ bureau for Merz, Galderma, and Allergan.
She also serves as a consultant and has served on
advisory boards for Merz, Galderma, and Allergan.
Dr. Vanaman has no financial interest in any of the
products, devices, or drugs mentioned in this article.

From the Department of Dermatology, University of Illi-
nois at Chicago; Goldman, Butterwick, Fitzpatrick, Groff
& Fabi, Cosmetic Laser Dermatology; and Department of
Medicine/Dermatology, University of California San Diego.
Received for publication April 4, 2015; accepted July 16,
2015.
Copyright © 2015 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000001832
Supplemental digital content is available for
this article. A direct URL citation appears in
the text; simply type the URL address into any
Web browser to access this content. A clickable
link to the material is provided in the HTML
text of this article on the Journal’s website
(www.PRSJournal.com).

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 Volume 136, Number 5S • Injectable Fillers: Décolletage
Patient exclusion criteria for filler injections
to the decolletage are few, but include hypersen-
sitivity to the filler or its components, a history of
hypertrophic scarring/keloids, and active inflam-
mation in the area to be treated.
ANATOMICAL CONSIDERATIONS
The layers of the superficial chest wall, from
superficial to deep, are skin, subcutaneous fat,
pectoralis major, fat, pectoralis minor, and ribs.2,3
In addition to these layers, there is fascia envelop-
ing both the pectoralis major and minor (Fig. 1).
The breast overlies the pectoralis major mus-
cle between the second and sixth ribs, between
the sternal edge medially and the midaxillary
line laterally. Superiorly, the breast extends to the
clavicle. The breast is tethered to the chest wall by
fibrous bands known as Cooper’s ligaments that
extend from the fascia of the pectoralis major to
the overlying dermis.4 In men, the nipple gener-
ally lies over the fourth intercostal space. Breast
size and shape varies greatly among women, mak-
ing nipple position inconsistent.
The pectoralis major is the larger and more
superficial muscle of the chest wall, arising from
the clavicle, sternum, and cartilage of the ribs
down to the sixth or seventh rib. The fibers con-
verge to insert on the humerus. The pectoralis
minor is a flat muscle that lies beneath the pec-
toralis major. It arises from the third, fourth,
and fifth ribs, anteriorly along the midclavicular
line, and inserts upon the coracoid process of
the scapula.5
For the physician performing rejuvenation of
the décolletage, it is important to note that the
skin in this area has a thinner epidermis and der-
mis compared with facial skin.6,7 In whites, the
epidermis and dermis have been reported to be
39–44 μm and 1319–1400 μm thick, respectively.8,9
The chest also demonstrates variable distribution
of subcutaneous fat and decreased pilosebaceous
units compared with facial skin.7,10 In 2004, Otberg
et al11 demonstrated that while the lateral fore-
head has a density of 292 vellus hair follicles per
Fig. 1. Frontal plane cross-section of chest anatomy between the second and
fourth ribs (area most commonly treated with fillers in the chest) demonstrating
from anterior to posterior: dermis most superficially, followed by subcutaneous
fat, pectoralis major muscle fascia, pectoralis muscle, breast tissue, and rib.
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
cm2, the chest has only 22 follicles per cm2. This
relative paucity of pilosebaceous units leads to
slower healing and a higher risk of complications
such as scarring, particularly with deeper chemi-
cal peels and ablative laser therapy.19 Thus, chest
rhytids are often more safely addressed with fill-
ers, microfocused ultrasound, neurotoxins, and
nonablative lasers rather than ablative techniques.
POLY-l-LACTIC ACID
Poly-l-lactic acid (PLLA) has numerous appli-
cations in medicine and has been used for over 30
years.10 Injectable PLLA (Sculptra; Sanofi-Aven-
tis, Bridgewater, N.J.) is a biocompatible, biode-
gradable, immunologically inert semipermanent
synthetic soft-tissue biostimulator that induces
gradual neocollagenesis by fibroblasts. It is gener-
ally injected into the reticular dermis and subcu-
taneous tissue planes; correction can last 2 years
or longer.10,12
Although originally Food and Drug Admin-
istration approved in 2004 for HIV-associated
lipoatrophy, PLLA gained additional approval in
2009 for correction of shallow to deep nasolabial
folds, contour deficiencies, and other facial rhyt-
ides. Since its introduction into cosmetic prac-
tice, PLLA has also been used in other locations
including the hands,7,12,13 neck,15,16 chest,7,12,16,17
and atrophic scars.15
In our office, we use a 16-mL dilution for the
rejuvenation of chest rhytides. At least 2 hours
prior to injection (but usually the day prior to
injection), a single vial of PLLA is reconstituted
with 1  mL of 1% lidocaine without or with epi-
nephrine 1:100,000 and 7  mL of bacteriostatic
water. Although the manufacturer recommends
sterile water for reconstitution, the vast majority of
physicians utilize preserved (bacteriostatic) water
as the preservative decreases patient discomfort
during cosmetic injections.18 The reconstituted
product is agitated with a Vortex Genie mixing
device (Scientific Industries, Inc., Bohemia, N.Y.)
immediately prior to injection, and then, 1.5 mL
is withdrawn into a 3-mL syringe. Next, another
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 Plastic and Reconstructive Surgery • November Supplement 2015
1.5  mL of bacteriostatic water is withdrawn into
the syringe, resulting in a combined total volume
of 3 mL. This step is repeated until a final total of
16 mL is mixed and withdrawn into the syringes. A
16-cc dilution cannot be done at the outset, as the
vial can only hold up to 10 cc of diluent.
No topical anesthetic, regional nerve block, or
ice application is used prior to PLLA injection in
our practice. Immediately prior to injection, the
treatment area is cleansed with alcohol. Using a
25-gauge, 1.5-inch needle (or cannula to mini-
mize reticular vein puncture), injections are car-
ried out starting with rhytides centrally between
the breasts then proceeding laterally and supe-
riorly in the plane of the subcutaneous fat using
a retrograde linear threading technique. The
boundaries of the treatment area are the supra-
sternal notch superiorly, the midclavicular line
laterally, and the fourth rib inferiolaterally, as
seen in Figure 2. The total product administered
varies by patient based on the severity of rhytides
and volume loss, with most patients receiving
16  mL (1 vial) per treatment session (Fig.  3). It
is important to avoid overcorrection, as the treat-
ment effect is gradual and will be more apparent
as neocollagenesis progresses. The area is then
vigorously massaged to ensure equal dispersion of
the PLLA microparticles. After the injections are
completed, a soapy cleanser is applied to the chest
to make the massage easier to perform. This injec-
tion technique is shown in Video, Supplemental
Digital Content 1, which demonstrates Dr. Fabi’s
injection technique utilizing PLLA in the décol-
letage, available in the “Related Videos” section
of the full-text article on PRSJournal.com or, for
Ovid users, at http://links.lww.com/PRS/B442.
Fig. 2. Map of area on the chest most commonly treated with
laser and MFU-V as well as injected with dermal fillers, with land-
marks used to create boundaries.
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Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Patients are counseled that the injection fluid
will be resorbed over the next few days and collagen
stimulation will follow. Patients are also instructed
to follow the “5-5-5” rule of massaging: massage the
treatment area for 5 minutes, 5 times per day, for
5 days. Injections are administered at least 4 weeks
apart, for a total of 3–4 treatments as needed.
Although the most common complications of
PLLA injection include pain, ecchymoses, edema,
pruritus, and hematomas, perhaps the best-known
complication of PLLA is nodule formation.10,11,13,14
Many techniques for minimizing the risk of
nodule formation have been described and are
listed in Table  1.6,14,15,19 Reconstitution of PLLA
with 5  mL of sterile water at least 2 hours prior
to injection is recommended by the manufacturer
(Sculptra product insert); dilutions with less than
5 mL are associated with an increased incidence
of nodules.18 Thus, many experts recommend
dilutions greater than 5  mL with reconstitution
overnight or longer.6,13,17,19 In a recent retrospec-
tive evaluation using PLLA for chest rhytides per-
formed at our practice, we found that dilutions
of 16 mL showed the best improvement in chest
rhytides, with no adverse effects.21 Posttreatment
massage is thought to aid in the dispersion of
PLLA microparticles, with a resultant decrease in
the incidence of nodule formation.6,13
HYALURONIC ACID
Cohen has previously described using injec-
tions of hyaluronic acid (HA) to correct chest
rhytides.6 For treatment of chest wrinkles and
furrows, 2–3  mL of nonanimal, stabilized hyal-
uronic acid (NASHA) is often required. NASHA
diluted with saline utilizing a 1:4 dilution (1 mL
of NASHA: 3 mL of bacteriostatic normal saline)
can be injected directly from the syringe using a
threading technique or as a combination of the
previously mentioned techniques. In the chest,
the longevity of correction is 6–8 months. For
optimal results, Cohen recommended combining
the NASHA injections with a series of 2–3 frac-
tionated nonablative laser treatments and a light
erbium laser peel a few weeks later.5
If injecting a HA in the décolletage, the authors
often utilize a 22.5 mg/mL monophasic HA filler
(Belotero Balance; Merz, Frankfurt, Germany),
which is a cohesive polydensified matrix HA that
has been demonstrated to have a low viscosity and
a resultant tendency to spread evenly. Prior to
injection, the product is mixed with 0.2–0.5 mL of
1% lidocaine without epinephrine. Using either
a 30- or 32-gauge needle, a serial puncture or
 Volume 136, Number 5S • Injectable Fillers: Décolletage

Fig. 3. Patient before (left) and 2 years after (right) treatment. Treatment consisted of 3 total vials
of PLLA administered as 1 vial per month at a 16-cc dilution for 3 consecutive months for chest
wrinkles and 2 intense pulsed light treatments for dyschromia.

enhancement of the neck, chest, and dorsal hands.

Video. Supplemental Digital Content 1, which demonstrates
Dr. Fabi’s injection technique utilizing PLLA in the décolletage,
is available in the “Related Videos” section of the full-text article
on PRSJournal.com or, for Ovid users, at http://links.lww.com/
PRS/B442.
retrograde linear threading technique is utilized
to inject the product. The injection plane with
this product should be the superficial dermis,
where the product will more easily intercalate into
the dermis than more viscous NASHA products,
giving the patient an even, smoother cosmetic
appearance without Tyndall effect.22
Restylane Vital Light (Galderma, Uppsala, Swe-
den) is available in parts of Europe and Asia for
This product contains 12  mg/mL of NASHA,
rather than the 20 mg/mL found in the remain-
der of the Restylane family of injectables (Q-med,
Uppsala, Sweden), and is available in 1- and 2-mL
syringes. This product is also injected in the mid to
deep dermis. Restylane Vital Light is available in
an autoinjector that is preloaded with 2 mL of the
filler and dispenses aliquots of 10 μL per injection,
resulting in a total of 200 doses per autoinjector.
The manufacturer claims that this microdroplet
deposition provides a more uniform deposition
of NASHA at the correct depth, thus decreas-
ing the incidence of nodules (http://www.q-
medpractitioner.com/International/Restylane/
Product-Range/Skin-rejuvenation-skinboosters/
Restylane-Injector/; accessed March 2015).
In the United States, a 20 mg/mL, 250,000 gel
particles/mL HA (Restylane silk; Galderma) can
be utilized instead, and the authors commonly
mix the product with 0.5  mL of 1% lidocaine
without epinephrine prior to injection. The injec-
tion plane with this product is the deep dermis,
and using either a 30- or 32-gauge needle, a serial
puncture or retrograde linear threading tech-
nique is utilized to inject the product.
In comparison with PLLA, correction
of rhytides on the décolletage with NASHA

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 Plastic and Reconstructive Surgery • November Supplement 2015
Table 1.  Techniques to Decrease the Incidence of
Nodule Formation with Injectable PLLA*
Do not overcorrect
Avoid intradermal injection
Use of dilutions >5 cc
Avoid excessive quantities of product injected per treatment
session
Space treatment sessions no sooner than 4 weeks apart
Overnight reconstitution
Posttreatment massage
*Reprinted with permission from Peterson JD, Goldman MP. Rejuve-
nation of the aging chest: a review and our experience. Dermatol Surg.
2011;37:555–571.6
requires more syringes and results last for 6–8
months.6 Thus, for most patients, it is more
cost-effective to utilize anywhere from 2 to 3
vials of PLLA, 1 vial per session, with sessions
spaced 1 month apart, which can provide
excellent correction for up to 2 years or lon-
ger without a touch-up. In the authors’ experi-
ence, PLLA also results in fewer nodules and
surface irregularities than NASHA, likely due
to the depth of injection.
CALCIUM HYDROXYLAPATITE
Finally, the authors are currently investigat-
ing the safety, efficacy, and patient satisfaction of
using 1 syringe of calcium hydroxylapatite with
lidocaine (CaHP) (Radiesse; Merz Aesthetics)
diluted 1:3 with bacteriostatic saline for treatment
of chest rhytides. In the study, one treatment arm
will be treated with CaHP alone and the other
with the combination of MFU-V immediately fol-
lowed by CaHP to determine if a synergistic effect
can be achieved when both a collagen stimulating
injectable and energy-based device are combined,
as has been seen clinically and histologically in
previous studies.23,24 Using either a 27-gauge,
1-inch needle or a 25- to 27-gauge cannula, CaHP
is delivered along the subcutaneous plane (at the
same depth as that of PLLA) using a retrograde
linear threading technique.
CONCOMITANT THERAPIES
Although it is beyond the scope of this article,
in addition to evaluation of wrinkles on the décol-
letage, one must also consider skin texture, ery-
thema, hyperpigmentation, reticular veins, and
telangiectasias that are better addressed by chemi-
cal peels, sclerotherapy, photodynamic therapy,
intense pulsed light, MFU-V, q-switched lasers,
and nonablative and ablative fractionated lasers.
Botulinum toxin may also be utilized to address
rhytides of the décolletage.25 As with cosmetic
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Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
rejuvenation of the face, the best results are often
obtained via a multimodal approach.
SUMMARY
As facial cosmetic procedures become increas-
ingly popular, so do rejuvenation procedures for
the décolletage. Rejuvenation of the décolletage
creates a seamless transition between the face and
nonfacial skin and contributes greatly to an over-
all more youthful appearance. When used alone
or in combination with other rejuvenation pro-
cedures, cosmetic injectables such as PLLA and
NASHA can be used safely in the décolletage to
address rhytides with minimal adverse effects if
proper patient selection, technique, and postpro-
cedure counseling are utilized. The use of CaHP
for the treatment of chest wrinkles may prove to
be another safe and effective treatment option.
Monique Vanaman, MD
808 S. Wood Street, Suite 380
Chicago, IL 60612
mboomsaad@gmail.com
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