Journal of Dermatological Treatment

ISSN: 0954-6634 (Print) 1471-1753 (Online) Journal homepage: http://www.tandfonline.com/loi/ijdt20

Neck rejuvenation using a multimodal approach in

Asians

Eun Jin Doh, Jiwon Kim, Dong Hun Lee & Je-Young Park

To cite this article: Eun Jin Doh, Jiwon Kim, Dong Hun Lee & Je-Young Park (2017): Neck
rejuvenation using a multimodal approach in Asians, Journal of Dermatological Treatment, DOI:
10.1080/09546634.2017.1395801

To link to this article: http://dx.doi.org/10.1080/09546634.2017.1395801

Accepted author version posted online: 03

Nov 2017.

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 Neck rejuvenation using a multimodal approach in Asians

Eun Jin Doh1, Jiwon Kim1, Dong Hun Lee1, 2, Je-Young Park3

1
Department of Dermatology, Seoul National University Hospital, Seoul, Korea
2
Institute of Human-Environment Interface Biology, Seoul National University, Seoul, Korea
3
Oracle Dermatology Center, Apkoo-Jung Department, Seoul, Korea
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Running head: Neck rejuvenation using multimodal approach

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Word count: 2,339

Figure count: 4

Table count: 3 us
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Conflicts of interest: none
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Funding sources: none

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Correspondence: Dong Hun Lee, M.D., Ph.D.

Professor
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Department of Dermatology, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu,

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Seoul 03080, Korea

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Tel.: 82-2-2072-2415, Fax: 82-2-742-7344, E-mail: ivymed27@snu.ac.kr

or Je-Young Park, M.D.

Chief Doctor

Oracle Dermatology Center, Apkoo-Jung Department, 23 Apgujeong-ro 30-gil, Gangnam-gu,

Seoul 06022, Korea

Tel.: 82-2-544-2777, E-mail: goodmorning26@hanmail.net

 ABSTRACT

Background: A multimodal approach is essential for neck rejuvenation because many factors

contribute to the aging of the neck.

Objectives: We evaluated the effect of combined therapy using microfocused ultrasound with

visualization (MFU-V), neuromodulator injection, and filler injection for neck rejuvenation.

Methods: Subjects were sequentially treated with three kinds of interventions in a single

session as follows: (A) MFU-V or calcium hydroxyapatite injection for restoring skin laxity;
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(B) hyaluronic acid filler injection for horizontal neck lines; and (C) neuromodulator

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injection for platysmal bands.

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Results: All ten patients showed clinical improvement of neck aging after combined

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treatment. Patients with more aged neck at baseline were more likely to show greater

improvement after treatment.

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Conclusions: Neck rejuvenation using multimodal approach is effective in Asians.
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Keywords
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Hyaluronic acid filler, microfocused ultrasound, neck aging, neck rejuvenation,

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neuromodulator
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 Introduction

Neck rejuvenation is one of the most challenging cosmetic subjects for clinicians. The

anatomical structure of the anterior neck is composed of several layers, including relatively

thin skin and superficial fat, platysma muscle, and deep fat (1). A multimodal approach is

required to rejuvenate the neck, because as the aging progresses, it deteriorates these multiple

layers (2). The various clinical aspects and anatomical characteristics of aging necks are why

it is difficult to achieve satisfactory cosmetic benefits after rejuvenation procedures.

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Specifically, there may be varying degrees of loosening of the skin, protrusion of the

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submental fat pads, prominent platysmal bands, and horizontal neck lines. These clinical

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features appear together rather than alone in aging of the neck (3-5).

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Surgical methods are considered a treatment of choice for severe neck laxity, but non-surgical

treatment for neck rejuvenation are associated with a little risk of scarring, and are preferred
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in patients with no or little skin excess, especially in Asians (6). Microfocused ultrasound
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with visualization (MFU-V), neuromodulator injection, filler injection, and ablative fractional

laser have been proposed as non-surgical approach to restore aging necks (2, 7-11). However,
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treatment using only one of these non-surgical treatment options is insufficient to improve

neck aging (2).

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Neck rejuvenation using a multimodal approach addresses the multiple facets of neck aging
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together and can overcome the limitations of single non-surgical treatment (2). Nevertheless,
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structured manuals and literature on multimodal approaches for neck rejuvenation are rare,

and previous studies of combined therapy were performed only in Caucasians (2). Aging

necks in Asians and Caucasians differ in many ways, such as skin thickness and fat

accumulation patterns. Therefore, we conducted a single-day session of treatment with a

combined approach including MFU-V, neuromodulators, and filler injections for neck

rejuvenation in Asians.
 Materials and Methods

Subjects

This study is a retrospective case series of ten Korean patients with aging of the neck who

visited a single dermatology clinic (Oracle Dermatology Center, Apkoo-Jung Department).

All subjects had Fitzpatrick skin type III or IV. Informed consent was obtained from each

patient and principles of the 1975 Declaration of Helsinki were adhered to.

Interventions
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All subjects were sequentially treated with three kinds of interventions in a single session for

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neck rejuvenation as follows: (A) MFU-V (Ulthera®; Merz North America, Inc., Raleigh, NC,

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USA) on lower neck including submentum and additional calcium hydroxyapatite (CaHA)

injection (Radiesse®; Merz North America, Inc.) in one patient (patient 2) for restoring skin
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laxity; (B) hyaluronic acid (HA) dermal filler injection (Belotero balance® or Belotero soft®;
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Merz North America, Inc.) for horizontal neck lines; and (C) incobotulinumtoxin A injection

(Xeomin®; Merz Pharmaceuticals GmbH, Frankfurt, Germany) for platysmal bands.

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Lidocaine 2.5%/prilocaine 2.5% cream (EMLA® cream; AstraZeneca Pharmaceuticals LP,

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Wilmington, DE, USA) was applied for 30 minutes as local anaesthesia prior to treatment.

After removal of EMLA cream, ultrasound gel was applied on the entire anterior neck. MFU-
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V was applied on submental area with a dual depth using 4.5-mm (4 MHz) and 3.0-mm (7
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MHz) transducers. The average number of MFU-V lines was 13/15/17/15/13 lines for each

five columns in submental area. The lower neck, except below the hyoid bone, was treated

using MFU-V with a dual depth using 3.0-mm (7 MHz) and 1.5-mm (10 MHz) transducers.

An average of 15 to 25 shots in three columns on each side was applied on the lower neck.

Only one patient (patient 2) received additional CaHA injection into the subdermis after

MFU-V for skin laxity. 1.5 mL of CaHA diluted with an equal volume of 2% lidocaine was
 used for the treatment of both lateral sides of the neck (12, 13). A 25-gauge cannula tip was

used for injections at the subdermis plane with fanning technique.

A HA filler was injected along the horizontal neck lines immediately after MFU-V.

Approximately total 1.0 mL of HA filler was injected with 30-gauge needle or at deep dermis

to subdermal layer using serial puncture technique.

Incobotulinumtoxin A was injected along the platysmal bands and was also injected above

and below the horizontal neck line. Two units of the neuromodulator was injected
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intramuscularly into the platysmal band every 2 cm. A 0.5 unit of incobotulinumtoxin A was

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injected into the subdermal area at 1 cm interval above and below the transverse neck line. A

total amount of injected neuromodulator in a patient did not exceed 50 unit.

Evaluation us
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Standardised digital photographs were taken before the treatment and 3 months after
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treatment to assess clinical improvement. Primary evaluation of efficacy was assessed by

three independent blinded evaluators (L.J.S., C.K.H., P.J.S.) who were not involved in
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treatment. An order of photograph of pre-treatment and post-treatment for each patient was
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randomised with reference key which is made by random number generation of Microsoft

Excel (Microsoft Corp, Redmond, Washington). Each reviewer was asked to select a post-
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treatment image of each patient from a pair of photographs. The evaluators also could choose
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"unchanged" if they did not recognise any change of neck aging between the two photographs.

When more than two evaluators selected the same image, that image was used as the result. If

the correct post-treatment image was selected, the patient's result was marked as “improved”.

Otherwise, if the incorrect image was selected, the result was considered “worse”.
 Secondary evaluation was performed using the scoring table (Table 1). The scoring table

based on the previously proposed classification of neck aging(3) was used to assess various

clinical features of the neck aging appear in combination. This scoring table was designed to

assign 0 to 3 points in each four categories: skin laxity, submental fat, platysmal bands, and

horizontal neck lines. The degrees of neck aging were graded on total scores of 0 to 12 points.

The reference photographs were provided to evaluators before the evaluation. Four blinded

evaluators (Y.D.A., K.J.W., Y.J.H., K.D.Y.) who were not involved in treatment or primary
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assessment, scored a pair of clinical pictures of each patient. An order of photograph of each

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patient was randomised.

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Data analysis

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In the secondary evaluation, the average of points assigned by four evaluators was used for
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further analysis. After test of normality using Kolmogorov-Smirnov and Shapiro-Wilk

method, paired t-test or Wilcoxon signed rank test was used to compare the pre-treatment
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score and the post-treatment score to assess the efficacy of the treatment. Correlation was
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analysed using Pearson’s correlation or Spearman’s correlation based on normal distribution

of values. A P value ≤0.05 was considered statistically significant. All data were analysed
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using SPSS 20.0 (IBM Corp, Armonk, NY, USA).

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 Results

A total of ten patients participated in this study. Demographics and detailed treatment

parameters and doses are shown in Table 2. All patients were women with mild-to-moderate

degrees of neck aging.

In a primary evaluation of efficacy, all ten patients were determined to have improved after

combined therapy for neck rejuvenation. In particular, six patients were classified as

improved by all three evaluators and two patients thought to be unchanged by only one
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evaluator, two other patients were considered as worse by one evaluator (Figure 1).

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In a secondary assessment of efficacy using the scoring table, the average of total score

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decreased from 4.05 (SE 0.666) to 2.325 (SE 0.443) after combined treatment. The difference

of total scores between the pre- and post-treatment was statistically significant in the paired t-
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test (P <0.001). Only one patient (patient 3), who had the lowest pre-treatment score, showed
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no change after treatment (Figure 2). In the detailed analysis, the Wilcoxon signed rank test

showed statistically significant differences in scores between before and after treatment in
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skin laxity and horizontal neck lines (Table 3). There was a statistically significant linear

correlation between initial total score and score difference after treatment based on Pearson’s
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correlation (r = 0.844, P = 0.002). These results suggest that patients with worse initial status
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of neck aging and higher initial scores were more likely to improve after treatment (Figure 3).
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Clinical photographs of pre-treatment, immediately after treatment, and 3 months after

treatment (patient 1) are shown in Figure 4. No significant adverse reactions were reported,

except tolerable pain, spontaneous disappearance of erythema, and swelling within 3-4 days.
 Discussion

Several changes such as obtuse cervicomandibular angle, loss of a distinct mandibular border,

protrusion of submental fat, prominent platysmal bands, and skin laxity contribute to aging of

the neck (14). Therefore, a combined approach aimed at improving various factors of neck

aging is important in neck rejuvenation (2).

The anterior neck is bordered by the inferior border of mandible, the anterior edge of the

sternocleidomastoid muscle, and clavicle (6). It is easy to overlook the submental fat when
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treating patients with aging necks, but submental fat must be treated in neck rejuvenation (1).

In addition, submental fat accumulation after age 40 occurs more frequently in Asians than in

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the Caucasians (15). MFU-V is known to be effective for non-surgical restoration of

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protruded submental fat (10). In addition to improvement of submental fat, mild-to-moderate
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skin laxity can also be treated with MFU-V (8, 16, 17). MFU-V spares the epidermis and

leaves no severe erythema or oedema, making it suitable for the first stage of multimodal
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treatment. While double depths using 4.5-mm and 3.0-mm transducers were generally

recommended in previous studies, we used double depths of 3.0-mm and 1.5-mm transducers
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herein for the lower neck area. We expected that using a 1.5-mm transducer would target the
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junction between the dermis and subcutaneous fat more precisely, because the average
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thickness from the skin surface to the dermis of Korean anterior neck is 1.5 mm (18).

Previous data have shown that using a 1.5-mm transducer may cause post-operative swelling
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and lead to difficulties in the following procedure (2). However, we observed only minimal

oedema in our study and there were no issues when performing the next procedure. In one

case, additional CaHA filler injection was applied after MFU-V. CaHA filler injection has the

advantage of reducing skin laxity due to collagen-stimulating effects (12).

Horizontal neck lines can be corrected with filler, intradermal neuromodulator injection, or
 thread lifting. HA filler injection is thought to be effective method for deep horizontal neck

lines(2) and a research has recently been published on the effect of injecting HA filler in a

horizontal neck line in Korean patients (19). The Cohesive Polydensified Matrix (CPM)-HA

filler is mainly used for the correction of moderate lines; Belotero® Balance(20) was used

primarily in this paper. Only one patient with the least horizontal neckline (patient 7, score

0.75) was treated with HA filler with lower concentration (Belotero® Soft).

Aging of the platysma leads to lose tonicity and attenuation of deep retaining ligaments on
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medial edge. In particular, patients with minimal (type I) or no platysmal decussation (type

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III) have a high incidence of goose neck deformity, which is an indication of surgery.

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However, strong decussation type (type II) rarely causes severe deformity is more common in

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Koreans (43%) than in South Americans or Caucasians (21). The development of platysmal

bands and exaggerated with contraction is a major problem of platysmal aging in Koreans,
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but it can be successfully corrected with neuromodulator injection. Neuromodulator was also
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injected to the inferior border of the mandible, and above and below the horizontal neck lines

(22). To avoid complications such as dysphagia or vocal cord movement abnormality, less
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than 50 unit of neuromodulator was injected.

The primary evaluation of improvement was performed as similar way which was described
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in previous literatures. In this paper, 100% of post-treatment images were selected with
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consent from two or more of three evaluators, and this efficacy was superior to the 66-80%
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efficacy of MFU-V alone in other studies (10, 16). In several previous studies, the three

scales (mild/moderate/moderate) used to assess the degree of improvement were subjective

and the criteria were often unclear among the evaluators. To overcome these limitations, we

used scoring table to assess degree of improvement in the secondary evaluation. The neck

aging score table is based on the category of neck degeneration that Brandt et al. proposed in

previous study(3) reflecting various clinical features of neck aging. Platysmal bands, which
 are visible only with contraction and subtle horizontal necklines, are intrinsic and normal;

these findings were set at 0-point.

We acknowledge several limitations in our study, including a small number of patients and

short-term follow-up. In addition, the scoring system requires further validation in many

patients. The study participants had a mild-to-moderate degree of neck aging (the mean score

of pre-treatment between 0.75 and 7). They also showed more prominent aging in terms of

laxity and horizontal neck lines, compared with submental fat or platysmal bands (Table 3).
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These characteristics can explain why statistically significant differences after treatment were

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observed only in horizontal neck and skin laxity in the detailed analysis. Additional studies

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are warranted in patients with severe protruding submental fat or platysmal band. In addition,

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patients with more severe neck aging showed more significant improvement after treatment;

it was a linear correlation. This suggests that patients with more severe neck aging may
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experience greater improvement after combined treatment than those who did not.
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In general, Asian skin tends to be thicker than Caucasian skin (18). It also has less severe

laxity problems. This means that the absolute indication of a surgical approach, such as
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patients with excess skin, is scarce in Asians. As a result, we emphasize the value of non-

surgical approaches to neck rejuvenation in the Asian population. Asians are good candidates
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for a non-surgical multiple approach for neck rejuvenation. We expect that neck rejuvenation
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using a multimodal approach is effective, because it can solve complex aging problems at the
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same time. Above all, there is a great advantage to performing all three procedures in a single

session without any significant complications. Combination therapy in one day may increase

patient satisfaction due to quick effect and short downtime. The complication of the

combination therapy is similar to the complication of injection of fillers or neuromodulators.

 Acknowledgements

We thank Dr. Lee, Dr. Cho, Dr. Park, Dr. Yang, Dr. You, and Dr. Kim for conducting the

evaluation.

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 2014;34(7):1099-110.

11. Chao YY, Chiu HH, Howell DJ. A novel injection technique for horizontal neck lines

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Recommendations. Plastic and Reconstructive Surgery. 2007;120(6S):55S-66S.

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14. Shadfar S, Perkins SW. Anatomy and physiology of the aging neck. Facial Plast Surg

Clin North Am. 2014;22(2):161-70.

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Ahn KY CE, Fanous N, Shibley-Gauthier P, Jung DH, Kim YH, Kim YK, Lee JB,
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Lee JS, Lee SK, Shirakabe Y, Shu T, Takahashi T, Wong JK, Yam C. Cosmetic Surgery of the
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Asian Face. 2005. In: Cosmetic Surgery of the Asian Face [Internet]. Stuttgart: Georg Thieme

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connect.de/products/ebooks/lookinside/10.1055/b-0034-55738.

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18. Lee Y, Hwang K. Skin thickness of Korean adults. Surgical and Radiologic Anatomy.

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19. Lee SK, Kim HS. Correction of horizontal neck lines: Our preliminary experience

with hyaluronic acid fillers. J Cosmet Dermatol. 2017.

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with cohesive polydensified matrix for soft-tissue augmentation and rejuvenation: a literature

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21. Kim HJ, Hu KS, Kang MK, Hwang K, Chung IH. Decussation patterns of the

platysma in Koreans. Br J Plast Surg. 2001;54(5):400-2.

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2017;140(1):9e-17e.

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 Tables

Table 1. Scoring table of neck aging

Skin laxity Submental Fat Platysmal Bands Horizontal neck

lines

0 No laxity No submental fat pads Only with neck contraction Subtle

1 Mild laxity Obvious Thin Mild

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2 Moderate laxity Prominent Moderate Moderate

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3 Severe laxity Drooping of chin Severe hypertrophy Deep

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 Table 2. Patient demographics

Patient Sex Age MFU-V HA filler Neuromodulater

no. (years) (depth) (total volume) (total unit)

1 F 63 3.0/1.5 mm Belotero balance, 1.4 46 U

mL

2 F 35 3.0/1.5 mm Belotero balance, 0.8 34 U

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*
CaHA (1:1 mL

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dilution) 1.5

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mL

4
F

F
45

58
4.0/3.0/1.5 mm

4.0/3.0/1.5 mm us
B. balance 0.6 mL

B. balance 1.0 mL
34 U

44 U
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5 F 65 3.0/1.5 mm B. Balance 1.2 mL 40 U
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6 F 58 3.0/1.5 mm B. Balance 1.0 mL 45 U

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7 F 52 3.0/1.5 mm B. Soft 1.8 mL 45 U

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8 F 56 3.0/1.5 mm B. Balance 1.5 mL 40 U

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9 F 52 3.0/1.5 mm B. Balance 1.4 mL 45 U

10 F 54 3.0/1.5 mm B. Balance 1.6 mL 42 U

*
Patient 2 received additional CaHA injection after MFU-V for improving skin laxity.
 Table 3. Scores of neck aging (average ± standard error)

Pre-treatment Post-treatment P

Skin laxity 1.30 ± 0.182 0.725 ± 0.142 0.008a*

Submental fat 0.775 ± 0.228 0.525 ± 0.216 0.131a

Platysmal bands 0.45 ± 0.162 0.325 ± 0.099 0.317 a

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Horizontal neck 0.007 a*

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1.525 ± 0.257 0.75 ± 0.154
lines

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Total score 4.05 ± 0.666 2.325 ± 0.443 <0.001 b*

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P < 0.05 us
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*a
Wilcoxon signed rank test was used.
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Because the differences in values showed normal distribution, the paired-t test was used.
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 Legends

Fig. 1. Evaluation of efficacy by three independent blinded evaluators

Fig. 2. Total score of neck aging

Fig. 3. Correlation between pre-treatment score and score difference after treatment. There
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was a statistically significant linear correlation, determined using Pearson’s correlation

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(r=0.844, P=0.002).

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Fig. 4. Clinical photographs of before and after treatment (patient 1).

(A) Pre-treatment (B) Immediate after the treatment (C) Post-treatment (3 month)
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