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Received: 14 October 2020    Accepted: 2 November 2020

DOI: 10.1111/jocd.13877

ORIGINAL CONTRIBUTION

The Aging neck—A Case base treatment algorithm

Or Friedman MD1  | Ava Shamban MD2 | Sabrina Fabi MD3 | Diane I. Duncan MD4 |

Ofir Artzi MD5

1
Maccabi Healthcare Services, Tel Aviv,
Israel Abstract
2
Univ Calif Los Angeles, Los Angeles, CA, Background: Effective nonsurgical treatments for the aging face are widely accepted
USA
and utilized. Although changes in the aging neck, often patients to seek esthetic reju-
3
University of California Los Angeles, Los
Angeles, CA, USA
venation protocols are neither well defined nor well designed. Increasingly, patients
4
Plastic Surgical Associates of Fort Collins, desire less invasive cosmetic treatments with less morbidity and downtime. A signifi-
P.C., Fort Collins, CO, USA cant challenge exists in managing expectations and educating patients about the pros
5
Tel Aviv Univ, Tel Aviv, Israel
and cons of a surgical approach compared to the plethora of nonsurgical options.
Correspondence When equipped with state of the art information and technique, using a multi-modal-
Or Friedman, Maccabi Healthcare Services,
ity nonsurgical approach, surprisingly outstanding results may be obtained.
Tel Aviv, Israel.
Email: or.friedman@gmail.com Aims: In this paper, we aim to revisit the neck's anatomy and then demonstrate cur-
rent nonsurgical techniques in managing actual cases.
Methods: To achieve that, we have utilized an intuitive four-point grading scale to
guide both physician and patient regarding appropriate treatment combinations.
Results: The proposed four-point scale was applied to six patients and their treat-
ment plan was described in detail.
Conclusions: Skin laxity is not the only factor that comes into play when assessing
the neck. careful analysis of the neck and face hold the key for treatment choice and
execution.

KEYWORDS

aging, energy-based devices, jawline, laxity, neck

1 |  I NTRO D U C TI O N 1.1 | The components of the neck subunit

The neck subunit often ages earlier and more noticeably than others
and is one of the most frequent motivations for patients to present
for rejuvenation options.1 Successful rejuvenation of the aging neck
requires a full understanding of every patient's esthetic needs and
formulating a tailored treatment plan customized to each patient. 2
When planning a neck treatment, whether isolated or in combi-
nation with a face treatment, the physician must respect and address
3
the neck subunit's different components.
In this article, a detailed review of the critical anatomic pearls
relevant to neck rejuvenation is performed, followed by suggestions
of grade oriented treatment combinations.
Figure 1.
1.1.1 | Platysma
The platysma is a broad muscle and originates at the deltopecto-
ral fascia and transitions cephalad across the mandibular border
as a component of the superficial musculoaponeurotic system
(SMAS).4 The platysma inserts into the modiolus and acts as a de-
pressor of the lower lip. 4 It is innervated by the facial nerve's cer-
vical branch. The marginal mandibular nerve (MMN) also acts as a

J Cosmet Dermatol. 2020;00:1–8. wileyonlinelibrary.com/journal/jocd© 2020 Wiley Periodicals LLC     1 |

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2       FRIEDMAN et al.
F I G U R E 1   Anatomical illustration of the neck area. Note the anatomical relationship between the fat compartments and the ligaments in
the face
lower lip depressor and innervates the mentalis muscles, providing
the lower lip's ability. 5
The platysma is continuous with the SMAS superiorly, and
caudally, its superficial fascia fuses with the pectoralis and deltoid
muscles fascia. The superficial cervical fascia covers the platysma
muscle. Maintaining this fascia's integrity is essential to (1) provide
an avascular plane of dissection and (2) maintain a robust platysma
that can be manipulated and tightened.6
1.1.2 | Retaining Ligaments and Filaments
Feldman's description of the retaining ligaments of the neck provides
the most accurate anatomic detail. 3 There are six named retaining
ligaments in the neck:
1. Mastoid-cutaneous ligaments
2. Platysma-auricular/earlobe ligaments (described initially by David
Furnas)7
3. Lateral sternocleidomastoid (SCM)-cutaneous ligaments
4. Submental ligaments
5. Mandibular osteocutaneous ligaments
6. Platysma-mandibular ligaments (or septum)
He also describes three filaments in the neck: (a) medial platysma
cutaneous filaments, (b) medial SCM filaments, and (c) skin crease
platysma filaments.3 The function of the ligaments and filaments is
to hold the cervical skin in place.
The mandibular osteocutaneous ligaments (MOCL) and platys-
ma-mandibular ligaments (PML) are often released in face and neck
lift surgery.
The MOCL defines the marionette lines' anterior border, whereas
the PML establishes the jowl's degree of descent. The release of
both ligaments is, at times, often needed for defining the jawline as
well as allowing access medially in the submental area. Dissection in
this region should be subcutaneous because the MMN lies immedi-
ately deep and superior to these structures.7
1.1.3 | Fat compartments
The fat compartments of the neck have been extensively studied.8
and divided into three regions: (a) superficial or supraplatysmal fat
(between the platysma and the skin); (b) intermediate or subplaty-
smal fat (between the platysma and the anterior digastric muscles);
and deep fat compartment (deep to the anterior digastric and sub-
mandibular glands).8
FRIEDMAN et al.
In the superficial plane, a layer of fat approximately 3 mm thick
should be left on the neck skin flap to avoid unnatural banding,
which is difficult or impossible to correct.
In the intermediate plane, subplatysmal defatting should be flush
with the anterior belly of the digastrics. Overreaction in this area
9
leads to the cobra deformity.
Larson and colleagues measured the weight of the different fat
compartments of the neck.8 They concluded that the supraplatysmal
compartment contains the most amount of fat, followed by the in-
termediate (subplatysmal) compartment. The deep fat compartment
has the least amount of fat and is not clinically significant. Several
clinical manifestations can be attributed to fat changes during aging:
1. Displaced fat from the facial fat compartments distorting the jaw-
line and disrupting the face to the neck transition zone. 2. Excess
submental fat blunts the cervicofacial angle. 3. Fat depletion result-
ing in a thin subcutaneous layer leads to a "skeletonized" appearance
of the neck.8 Volume adjustment treatments should be incorporated
while establishing a treatment plan.
1.1.4 | Skin
The neck's skin contains a complex collagen network involving the
papillary and reticular dermis, fibroseptal network intermixed with
subcutaneous fat, and underlying fibrous fascia.10 These deeper tis-
sue layers act in concert with the more superficial dermal skin layers
to create the skin's tone, quality, and durability. In addition to ptotic
skin, the aging neck frequently displays subcutaneous and subplaty-
smal fat, which blunts the cervicomental angle and contributes to an
11
aged esthetic. Controlled disruption and subsequent remodeling
of dermal and subdermal collagen is the underlying mechanism of
nonsurgical skin rejuvenation. The gold standard for the treatment
of skin laxity is surgical excision. Yet in recent years, the stigma of
surgery, fear of morbidity, and increased time in the public eye via
social media has led many patients to desire less invasive treatments,
11
earlier in life, with less morbidity and downtime.
1.1.5 | The marginal mandibular nerve
The MMN exits the parotid gland and travels under the parotid-
masseteric fascia until it reaches the facial vessels. It passes from
under the deep fascia to a sub-SMAS location. It crosses the facial
artery at 23.1 mm from the gonial angle and 3.1 mm superior to it
(approximately one-fourth of the distance from the gonial corner to
the pogonion): This is the danger zone for the MMN, the location
at which it is most vulnerable to injury and sub-SMAS dissection in
this area should proceed with caution. The terminal branches of the
MMN are located continuously deep to the SMAS at a mean distance
of 9.7 ± 1.2 mm superior to the MOCL. 5
Although the MMN is never subcutaneous, it can be inadver-
tently injured even with a planned subcutaneous dissection. This
happens when rapid blunt scissor dissection passes under the skin
|
      3
with inadvertent penetration of the platysma. Monopolar cautery in
this area can also result in neuropraxia. 5
1.1.6 | Cervical branch of the facial nerve
The facial nerve's cervical branch exits the inferior parotid gland
and immediately changes planes from deep to the parotid-mas-
seteric fascia to a subplatysmal plane. It has multiple branches,
the lowermost being 4.5 cm below the margin of the mandible.12
Terzis reports 1 to 3 nerve branches entering the undersurface of
the superolateral third of the platysma.12 In their cadaver dissec-
tion, Sinno and Thorne identified only one cervical branch of the
facial nerve in all 16 cadavers, with branching occurring at the fa-
cial vessels' level to supply the platysma. The main cervical branch
continues anteriorly to the medial edge of the platysma below the
thyroid cartilage.13
Trévidic and Criollo-Lamilla have described the role of the cervi-
cal branch of the facial nerve in the formation of platysma bands.14
They followed 25 patients with facial paralysis over ten years and
found no platysma bands on the paralyzed side than the good side.14
Recurrent platysma banding is a common and frustrating adverse se-
quela of neck lift surgery. Whether denervation of the platysma will
play a critical role is yet to be determined.14
1.1.7 | The great auricular nerve
The great auricular nerve is the most commonly injured in facelift
surgery.15 The following is a fail-safe method designed to avoid
nerve injury: A 30-degree angle is designed with the anterior limb
drawn perpendicular to the Frankfurt horizontal line extending from
the middle of the ear lobule.15 A second line is drawn 30 degrees
posterior to this vertical line. The great auricular nerve will be found
within the boundaries of this angle.15
1.2 | Patients classification and case examples
Patients are classified according to the laxity of their neck skin:
Grade I (no laxity), Grade II (mild laxity), Grade III (moderate laxity),
and Grade IV (severe laxity). All the patients signed informed con-
sent forms for the treatments and publication of images for scientific
purposes.
1.3 | Patient[p1] #1—Grade I (no laxity)
1.3.1 | General
Grade 1 Patients have minimal to no laxity. Some may present with
excessive submental fat and possibly a hypertonic platysma leading
to a lack of definition between the jawline and neck.
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4       FRIEDMAN et al.

1.3.2 | Pathologies observed

This young type 3 Hispanic woman does not have any true skin lax-
ity but lacks a clear definition of where her jawline ends. Her neck
changes are commonly manifested in a younger cohort where the
pathology begins at the bony level. A genetically shortened mandi-
ble is usually accompanied by a recessed or inadequate mentum and
a flattened midface. This patient has excellent skin quality along with
excessive submental fat and a hypertonic platysma. As this patient
manifests all three of these pathologies, she requires a multimodal
treatment approach to provide optimal results.

1.3.3 | Treatment modalities and techniques

The first area addressed was the supraplatysmal fat pad. The patient re-
ceived a cryolipolysis treatment followed six weeks later with two vials of
kybella. As both procedures require a four- to 12-week period to realize
maximal results, eight weeks were determined to be an adequate time
lapse before the next treatment type. The patient was then injected with
cross-linked hyaluronic acid with a high G prime, Restylane Lyft, in her
midface onto periosteum with a needle in the distribution previously de-
scribed. (reference here). There are data to suggest that needling the peri-
osteum also stimulates new bone formation. A significant amount of filler
was used carefully to reestablish normal contours, which will secondarily
lift the skin, thereby helping the mandibular angle. Next, Restylane Lyft
was added to the mandible body, the posterior mandibular angle, and the
mentum, using a cannula and needle combo. Her treatment took place F I G U R E 2   Patient #1 Before and after treatment of typical Grade
over 2-3 sessions to allow the skin to re-drape over the product. Next, 1 Neck and jawline aging. Note the minimal skin laxity as evident by a
suspension threads were inserted to elevate the skin further up and back slightly blunted neck and jawline angle, on the left-hand side before. On
away from the mandible. Finally, neurotoxin was injected in the Nefertiti the right, after
pattern along the platysma's horizontal borders and into the vertical plat-
ysmal bands to relax. The pull of her hypertonic platysma. 1.4 | Patient #2—Grade[p2] II (mild laxity)
Loss of demarcation between the end of the mandible and the
beginning of the neck due to a genetically short mandible and poorly 1.4.1 | General
defined mentum. Excessive platysma tone. Good skin elasticity.
Possible excessive submental fat. Patients with mild skin laxity (grade II) and poorer skin quality. Most
will present excess supraplatysmal fat and jowls resulting from man-
dibular bone resorption.
1.3.4 | Tips and Pearls Most patients will complain of having an obtuse cervicomental angle.

Figure 2.
1.4.2 | Pathologies observed
1. A combination approach designed to address all of the compo-
nents of a prematurely aging neckline is effective as long as it 60 yo female presented with grade II neck. Had a combination of ex-
is instituted in a stepwise fashion. Each component is treated cess supraplatysmal fat and jowls, mandibular bone resorption, skin
separately. Begin with fat removal, continue with augmenting laxity, and poor skin quality.
deficient bony prominences to achieve lift and definition.
2. Next, eliminate pull from hypertonic platysma and use absorbable
sutures to lift the skin further away from the mandible creating 1.4.3 | Treatment modalities and techniques
the appearance of a beautifully sculpted jawline and chin.
3. If necessary, consider the use of an external tissue tightening de- Laser-assisted tumescent liposuction of the neck and jowls using
vice, either radiofrequency or focused ultrasound. the 1064nm laser (Cooltouch) at 10Watts, for 15 total minutes,
FRIEDMAN et al. |
      5

not allowing epidermal temperatures to reach beyond 42C using

the FLIR camera system TO REMOVE EXCESS FAT ON NECK AND
JOWLS AND LIFT SOME LAX SKIN.
Three months later, a combination of IPL (lumenis IPL), using
the 560 filter, double pulsed at 3.5 ms pulse duration, 20ms pulse
width, 17 J, followed by the fractionated CO2 laser using the Fraxel
Repair System, Solta. at 25mJ/30% density top of neck, 22.5% mid
neck/15% density lower neck.
Three months after that, two cc's of Juvederm voluma—along
chin/ prejowl sulcus and angle of mandible/jawline immediately fol-
lowed by 40 units of ONA (4 units each DAO, four units mentalis,
and 28 units split between both platysmal muscles).

1.4.4 | Tips and pearls

Figure 3.

1. IPL significantly improves the dyschromia and seems to add

some thickness to the regenerated skin.
2. Adding some filler after the skin had been tightened helps deli-
cately restoring actual volume loss.
3. Toxin Can most times be considered and is useful in all neck cases.

1.5 | Patient[p3] #3—Grade III (moderate laxity)

1.5.1 | General

Grade III patients present moderate laxity as well as other aged com-
ponents. Grade 3 neck rejuvenation often requires a multi-modality
approach to address the multiple facets of the aged neck. It is essen-
tial to name the treatment goals and course to meet patients' expec-
tations and avoid disappointment.

1.5.2 | Pathologies observed
F I G U R E 3   Patient #2 Before and after treatment of typical
62-year patient, hyperkinetic platysma—loss of jawline, and submen- Grade 2 Neck and jawline aging. Note the progressive loss of
jawline definition, the displacement of facial fat compartments,
tal contour.
specifically in this patient, accumulating submental fat on the left-
hand side before. On the right, after

1.5.3 | Treatment modalities and techniques

Platysmal neuromodulator injections were performed 2-4 weeks
before addressing the muscular component. In the same visit,
under tumescent anesthesia, a percutaneous radiofrequency
probe (In mode, Yoknaam, Israel, Facetite, or Accutite) was uti-
lized to liquefy the adipose tissue for immediate manual lipo-
suction (focal areas) and to stimulate collagen formation and
contraction via thermal effects. As a rule of thumb, 0.2-0.5kJ per
area is desired.
If possible, a small amount of fat (mainly jowls and submentum)
is manually withdrawn. RFAL (Radiofrequency-assisted liposuction)
might achieve up to 35% soft tissue contraction at up to 12 months.
The RF energy is emitted only between the two electrodes, and the
facial nerve and its branches run in the layer below the SMAS. It is
important to emphasize that the practitioner should stay close to the
dermis to ensure that the electrode is above the SMAS.
Immediately following RFAL, at the same sitting, ablative frac-
tional CO2 laser (Acupulse, Lumenis, Yokneam, Israel. Deep mode,
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6       FRIEDMAN et al.

F I G U R E 4   Patient #3 Before and after

treatment of typical Grade 3 Neck and
jawline aging. In low BMI patients, the
main signs would be the change in the
jawline contour. Fat displacement might
not be as evident due to a small amount of
fat. Yet the jawline becomes more square,
thinning the skin and subcutaneous tissue,
exacerbating transitions between esthetic
units. Note the break in the middle of
the jawline and the loose submental
tissue on the left-hand side. On the right,
after

F I G U R E 5   Patient #4 Before and

after treatment of typical Grade 4 Neck
and jawline aging. Note the severe skin
and soft tissue laxity, poor tine and
texture, and platysmal banding. This
patient also notes the large compartment
displacement and excessive accumulation
in the submental region (a common
complaint) on the left-hand side before.
On the right, after

1.5.4 | Tips and pearls

Figure 4.

1. Several studies have demonstrated that ablative fractional CO2

laser immediately following other modalities (vascular lasers,
MFU-V, QS- switched laser) to the neck area significantly im-
prove post-treatment results.
2. This combination has not been demonstrated to increase scar-
ring or other unwanted adverse events in the authors' experience
than just performing either the RFAL or ablative fractionated laser
treatment alone.

F I G U R E 6   Patient #5 Before and after treatment of typical

Grade 4 Neck and jawline aging. Note the severe skin and soft
tissue laxity, poor tine and texture, and platysmal banding. In this 1.6 | Patient #4—Grade IV (severe laxity)
low BMI, the patient considers the treatment of the platysma and
neck contour. On the left-hand side before. On the right, after 1.6.1 | General

We consider level IV neck deformities as the most difficult for an odd

Fluence-12.5mJ, Density-5%-10% followed by Superficial mode, reason. They are more technically involved, but for many clinicians, the
Fluence 120mJ, Density 40%) is used to produce significant, sus- biggest challenge is managing expectations. When a patient comes in
tained improvement in superficial skin laxity and texture in the neck with severe skin and soft tissue laxity, poor tine and texture, and platy-
and jowl area. smal banding, they will frequently mimic a facelift's effect by pulling the
FRIEDMAN et al.
skin up toward their ears. Then, the next statement they make is, "But I
don't want a facelift, just a little something to take this away. "They have
read about Thermage and Ulthera and hope that something like that will
give the desired effect. As there is a range of different challenges in level
IV patients, three different patients are presented and discussed.
1.6.2 | Pathologies observed
This late-middle-aged Caucasian woman has severe lower face,
jawline, and neck laxity. She lacked a defined mandibular angle and
submandibular shadow. Jowls were prominent bilaterally, her cer-
vicomental angle was obtuse, and the submental skin was sagging.
Severe localized lipodystrophy was present in the submental and the
bilateral lateral neck region. The lipodystrophy masked any platys-
mal banding. The skin was thin.
1.6.3 | Treatment modalities and technique
The patient was treated under general anesthesia due to the com-
plexity and surface area. Tumescent fluid 450 ccs were infused.
Liposuction was performed with a 3mm cannula, with care taken to
avoid over resection or too much superficial liposuction. Monopolar
radiofrequency energy (Thermi, Dallas, Texas) was applied in three
sections: right lateral neck, central submental neck, and left lateral
neck. A FLIR camera was used to minimize the risk of a burn. I treated
each area until the skin temperature on FLIR read 42 degrees. In ret-
rospect, I would not dwell so long in each section but would address
minimally, until the FLIR temperature reached only 40 degrees. If
needed, each area's second light treatment could be performed once
the area cooled a bit. This patient was not treated with any other mo-
dality. No skin was excised. No platysmaplasty was performed.
This patient had a complication due to my overuse of energy in
a region with thin skin. The "heat sink" effect of this device was re-
vealed, with I checked FLIR readings at the case conclusion—all treated
areas measured 45 degrees. While no blistering was present during
the procedure, five days later, two small ischemia regions appeared in
the treatment region. One was located at the cervicomental angle and
F I G U R E 7   Patient #6 Before and after treatment of typical Grade 4 Neck and jawline aging. The patient's overall face was exhibiting the same
severe skin and soft tissue laxity, poor tine, and texture. These low BMI patients are often over or undertreated "Injectors" might over inject, "Facial
surgeons" might focus on "pulling" the skin. Careful consideration of the patient's wishes, combined with pictures of her younger self, holds the key
for successful treatment in this group, on the left-hand side before. On the right, after
|
      7
another in the immediate preauricular region on the left. These areas
took about five weeks to heal fully. She was not as upset as I was about
the problem, as her skin contraction was phenomenal. She did wear a
light compression jaw bra at night for three months postop.
1.6.4 | Tips and pearls
Figure 5.
1. Radiofrequency-assisted liposuction can achieve surprisingly
good results in well-chosen candidates.
The best patients are younger, with a "double chin" or lack of
lateral jawline definition. Middle-aged patients without noticeable
platysmal banding can also achieve dramatic improvement. Several
different types of subdermal devices are available. Both monopolar
and bipolar devices work well.
A newer modality, using helium plasma-driven radiofrequency, is
excellent for this application as the energy is fractional, and the skin
does not heat up as much as previous devices.
2. Be careful in treating secondary necks with energy-based de-
vices. The relative fibrosis and ischemia make these patients prone
to more complications.
1.7 | Patient #5—Grade IV (severe laxity)
This older patient also wanted to minimize the procedure risk and
chose a minimally invasive approach.
Her neck was not overly fatty. She did have platysmal banding.
The patient requested only a three-day downtime.
1.8 | Pathologies observed
This 58-year-old woman had a gonial notch due to bony atrophy, ac-
companied by a prominent jowl bilaterally. She lacked a well defined
submandibular angle. Her cervicomental angle was obtuse. Skin lax-
ity was also noticeable in the lower neck in the suprasternal region.
This problem is tough to address, even with a surgical neck lift.
 |
8       FRIEDMAN et al.
1.9 | Treatment modalities and technique
The patient was treated under general anesthesia. 325 cc tumescent
fluid was infused along the jawline and the neck region down to the
suprasternal notch. Liposuction was performed with a 3mm cannula
at 10mm HG to undermine and loosen the skin. Helium plasma-
driven radiofrequency (Renuvion by Apyx Medical, Clearwater,
Florida) was used to heat the soft tissue using the following set-
tings: 65% power and 1.5 liters/ minute flow rate. Time on tissue
was 4.2 minutes for the entire neck. The 3 mm cannula was used to
remove residual helium and any remaining fluid to minimize postop-
erative gas retention. The three access ports at the earlobe bases
and submental regions were well vented to permit gas escape. Small
incisions were closed with 5-0 subcuticular Vicryl sutures.
The second part of the treatment employed two Double Forte
PDO 100  mm threads per side (Miracu, Mission Viejo, California).
Using the earlobe access points, the threads were introduced and
anchored at the platysma's medial border. The first thread was
placed at the level of the cervicomental angle. Thread #2 was placed
using the same access point but was anchored 2 cm lower, in the
upper central neck. Threads were tightened until clinical appearance
was good. The remaining ends were trimmed. The patient did wear a
jaw bra at night for three weeks.
1.10 | Tips and pearls
Figure 6 and Figure 7
1. Treating the platysma with a minimally invasive approach is
challenging. By advising the patient that little or no improvement of
platysmal banding may occur, expectations can be best managed.
2. The combination of RF energy plus an internal anchoring sys-
tem creates an internal support system previously only achievable
using open surgical techniques. While PDO threads have been used
for many years in this area, a combination of undermining tissue plus
thread placement is needed to make a long term change.
2 |  CO N C LU S I O N S
Skin laxity is not the only factor that comes into play when assessing
the neck. Male patients have less impressive results, likely due to
less skin contraction after undermining because of the skin's seba-
ceous nature. Also, the obese/heavy neck poses a challenge, as it is
hard to provide a smooth contour with fat removal only, and these
patients often need skin resection.
Ptosis of the submandibular glands should be noted preoperatively.
The anterior approach provides access to the submandibular glands for
resection, suspension, or direct platysma plication over the glands.
C O N FL I C T O F I N T E R E S T
None.
AU T H O R C O N T R I B U T I O N S
Friedman O. MD contributed the introduction anatomical preface
and conclusions. Shamban A.MD. contributed the first patient. Fabi
S. MD contributed the second patient. Artzi O. MD contributed the
third patient. Duncan D. MD contributed the last patients. None of
the authors have any conflicts of interest to report. All the patients
signed informed consent forms for the treatments and publication of
images for scientific purposes.
ORCID
Or Friedman  https://orcid.org/0000-0002-4362-7909
Ofir Artzi  https://orcid.org/0000-0003-1391-5843
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How to cite this article: Friedman O, Shamban A, Fabi S,
Duncan DI, Artzi O. The Aging neck—A Case base treatment
algorithm. J Cosmet Dermatol. 2020;00:1–8. https://doi.
org/10.1111/jocd.13877