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Video 12.3 Lipografting of the malar area assisted by
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stromal enriched lipograft.
are prescribed during the following 7 postoperative days. Return to mild physical activities is
allowed after the third postoperative week.
Bimodal compression is recommended.
12.4 Problem-Based Examples/
Cases
12.4.1 Case 1
A 43-year-old lady presented to our department requesting face and neck rejuvenation (▶ Fig. 12.3a–d).
She underwent SEL contouring of the face and
nose using 43mL of lipograft and Renuvion application in the neck area. Postoperative photographs taken 18 months after the procedure are
shown in ▶ Fig. 12.3e–h.
12.4.2 Case 2
A 45-year-old lady presented to our department requesting face and neck rejuvenation (▶ Fig. 12.4a–c).
She underwent SEL contouring of the face using
39 mL of lipograft and Renuvion application in
the neck area. At the same time, she had closed
rhinoplasty perfor med. Postoperative photographs taken 24 months after the procedure are
shown in ▶ Fig. 12.4d–f.
12.4.3 Case 3
A 63-year-old lady presented to our department requesting face and neck rejuvenation (▶ Fig. 12.5a–d).
She underwent round facelifting and SEL contouring of the face and nose using 62 mL of lipograft and Renuvion application in the neck area.
She had at the same time upper and lower
12.5 Discussion
blepharoplasty performed. Postoperative photographs taken 12 months af ter the procedure
are shown in ▶ Fig. 12.5e–h.
12.4.4 Case 4
A 73-year-old lady presented to our department requesting face and neck rejuvenation (▶ Fi g. 12.6a–c).
She had undergone two previous facelifting procedures in a different clinic. She underwent SEL
contouring of the face and nose using 54 mL of
lipograft and Renuvion application in the neck
area. She had at the same time upper and lower
blepharoplasty performed. Postoperative photographs taken 18 months after the procedure are
shown in ▶ Fig. 12.6d–f.
12.5 Discussion
Facial aging presents a challenging problem for
plastic and aesthetic surgeons; it is a multifactorial,
multistep process that involves structural and volumetric changes in the skin, muscles, skeleton, and
adipose tissue.
only by gravity but also by reabsorption and repositioning of the facial adipose system. Sterodimas et
al recommend, as a rule, slight undercorrection of
the contour of the neck to allow for postoperative
fat lysis, which amplifies the result.
cannulas, not performing superficial liposuction,
turning the suction off when exiting incisions, crisscrossing areas, constantly analyzing areas by visual
and tactile means, and proper positioning all can
help reduce the chance of contour irregularities.
Facial rejuvenation with autologous fat has the advantage of replacing or augmenting tissue with like
15
tissue.
can correct cosmetic defects that are caused by loss
of subcutaneous tissue, such as atrophy of the face
due to significant weight loss, wrinkles, and facial
involution due to aging. Clinical use of autologous
fat grafts for facial soft-tissue augmentation has
grown in popularity in the plastic surgery community in the past 10 years. Regenerative cellbased strategies such as those encompassing the
use of stem cells have shown that autologous ADSCs
offer the possibility of finally fulfilling the key principle of replacing like with like as an aesthetic
16
filler.
cells that display a regenerative capacity by the
paracrine release of growth and differentiation factors. ADSCs are responsible for the rejuvenation
13
Facial tissue descent is caused not
14
Using small
Autologous fat transplantation to the face
ADSCs are multipotent mesenchymal stem
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Neck Lift and Fat Grafting to the Neck
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Fig. 12.3 (a–d) Preoperative photographs of a 43-year-old lady requesting face and neck rejuvenation. (e–h) Postoperative
photographs of a 43-year-old lady, 18 months after the procedure.
138
12.5 Discussion
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Fig. 12.4 (a–c) Preoperative photographs of a 45-year-old lady requesting face and neck rejuvenation. (d–f) Postoperative
photographs of a 45-year-old lady, 24 months after the procedure.
capabilities of fat grafts, and their use has shown
lower reabsorption rate due to improved angiogenesis and reduced inflammatory response. In SEL,
ADSCs are used in combination with lipoinjection.
An SVF containing ADSCs is freshly isolated from
the aspirated fat and recombined with the adipose
scaffold. This process converts relatively ADSC-poor
aspirated fat to ADSC-rich fat. ADSCs remain the
most widely used by cosmetic surgeons as they
have the potential and capability to differentiate
into mesenchymal, ectodermal, and endodermal
lineages and are easily accessible to harvest. The regenerative effects of ADSCs on facial aesthetics have
been shown at the histologic and cellular level.
Regeneration of elastin and collagen fibers, improvement in capillary density, and reduction of inflammation have been reported. Understanding of
the facial anatomy lends greater precision to our
ability to rejuvenate the aging face. The diminished
volume of a specific facial fat compartment leads to
an excess skin envelope and the illusion of a more
17
prominent facial fold. The SEL technique can be
applied to the lateral two-thirds of the brow, the
nasojugal fold, the malar and buccal fat pads, the
nasolabial fold, the lips, and the perioral region.
Augmentation of fat compartments by the SEL technique has the following effects: it increases the
anterior projection; it diminishes the ptotic fold
pseudoprojection; and a youthful facial contour and
harmony is recreated.
Electrosurgical energy flows into the application
18
site for a brief inter val, then quickly disperses out.
This results in precise, predictable eff ects on the
skin and underlying connective tissue. Rapid heating of the subcutaneous tissue, and subsequent
skin tightening, occurs as the plasma rapidly gives
1
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Fig. 12.5 (a–d) Preoperative photographs of a 63-year-old lady requesting face and neck rejuvenation. (e–h) Postoperative
photographs of a 63-year-old lady, 12 months after the procedure.
140
12.5 Discussion
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Fig. 12.6 (a–c) Preoperative photos of a 64-year-old lady requesting face and neck rejuvenation. (d–f) Postoperative
photos of a 64-year-old lady, 2 months after the procedure.
up energy to the surrounding tissue with each
pass of the device. With each stroke of the Renuvion device, the RF energy encounters tissue with
varying impedance and will continuously change
paths of heat transfer. There is minimal depth of
thermal effect and prevention of overtreating tissue even with multiple passes while maximizing
treatment of untreated tissue. The release of helium gas in the subdermal tissue helps rapidly dissipate the accumulated thermal energy. Because the
device rapidly heats a small segment of subcutaneous collagen to 85 °C, strong immediate contraction is generated within 0.044 seconds.
postliposuction tissue treatment is followed by
very visible improvement at the 24-hour post-op
mark. Results can continue to improve over a year,
as infiltration of new collagen within the adipose
stroma occurs. Restoration of the adipose framework can recreate a firm rather than flabby feel of
the soft tissue, along with a defined shape. Although
these devices have proven effective in achieving
soft-tissue contraction, the process of heating and
maintaining that temperature for extended periods
19
A rapid
can be time-consuming. In devices without an external temperature monitor, the skin surface can
become overheated, causing occasional blisters or
burns. One of the main challenges associated with
percutaneous delivery of energy for the purpose of
thermal-induced collagen tissue contraction is the
balance that must be achieved between heating the
internal tissues enough to achieve the desired contraction while maintaining safe external tissue temperatures. Patients who should not be treated with
Renuvion for neck contracture include women who
are pregnant or breastfeeding; patients with an
open sore in the treatment region; patients with
compromised healing such as oxygen dependence,
diabetes if poorly controlled, and autoimmune disease; and patients with severe tissue laxity in the
neck region.
The regenerative effect of fat has been widely
proven, both clinically and histologically, and includes neoangiogenesis and collagen synthesis,
which determine an increased density of the extracellular matrix, stem cell transformation into
fibroblasts secreting collagen, and better volume
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retention when combining plain lipotransfer with
enzymatically processed adipose tissue. With SEL,
a combination of effects is achieved: better take of
the injected fat because adipocytes are more prone
to survive and the isolated stem cells rejuvenate
the skin, improving its quality, as shown by previous studies.
bone volume, and a rejuvenated skin are restored
in a single proced ure. The fat is naturally stem
cell d eficient in terms of their concentration for
the surgeon’s purpose, and SEL allows the concentration of regenerative elements and thereby
biologically supercharging the fat to increase the
possibility of engraftment for a tissue that has
been completely disconnected from its vascular
network and freely transferred into variably hostile bioenvironments. Conversely, the SVF is reestablished into its native niche, the adipose tissue,
which will help its engraftment, durative survival,
proliferation, and biological activity. Basically, all
the significance of the action is transferring fat
containing a higher concentration of stem cells,
pericytes, and other bioactive elements of the SVF
to counteract the inevitable ischemic damages deriving to the transferred devascularized tissue. The
two histological components of SEL assist each
other in overcoming the biological challenge of devascularization and transfer.
volume of fat is necessary to obtain a durable lipograft, thanks to the combination with the stromal
fraction. This implies a lower risk of causing a puffy
face intraoperatively. In our series of treated patients, a single session of SEL-based lipografting
has been successfully performed in all cases.
Although the desirable outcome is to produce the
requested augmentation and cutaneous biostimulation of the facial region by autologous fat grafting
in one stage, the patient should be advised that a
secondary procedure may be needed to accomplish the desired result. More basic and clinical research is necessary, but the preliminary encouraging impression is that the combination of SEL to
traditional face procedures is safe and effective
and the prolonged duration of the grafted fat is
such that repeat procedures are rare, and this may
be attributable to a more stable inhabitation of the
recipient site thanks to the stromal component
and its proregenerative action. The long-term effect of Renuvion contracture to the neck needs to
be further assessed in a controlled double-blind
study.
1,15
Lost fat volume, reabsorbed
6
With SEL, a lower
12.6 Conclusion
The ideal substance for soft-tissue au gmentation still
eludes physicians, but fat grafting through a blunt
cannula seems to be the safest of all of the fillers
used; in the hands of an experienced surgeon, it can
provide long-lasting, natural-appearing structural
changes. SEL restores the three-dimensional projection and overall shape of the face to more youthful
contours and eliminates shadowing and muscle to
skin interactions. The Renuvion technology appears
to be safe and well tolerated by patients for neck
tightening. SEL is an effective and novel antiaging
therapeutic agent in cosmetic surgery.
12.7 Expert Commentary by
Dr. Slavin
The author describes a novel and highly personalized approach to fat grafting of the neck, addressing the vexatious issue of fat graft volume loss
with new technology. The SEL method provides a
more sustained retention of adipocytes. In keeping
with current trends of nonsurgical rejuvenation of
the face and neck, the author stresses on the importance of combinations of techniques and modalities in order to achieve multiple goals: volume
replenishment, skin tightening, and improvement
in skin surface quality.
These nonsurgical approaches are also useful
adjuncts to surgical treatment of more extreme
degrees of skin laxity, suggesting that the future of
facial and neck rejuvenation will be a palette of
choices and combinations. For the patient with degrees of facial atrophy and skin laxity—a common
finding—filling areas of deficiency with reliable fat
cell additives has become the primary treatment.
As always, it is the experienced clinician who
understands all of the available options—both surgical and nonsurgical—who is best able to meet
the often-complex needs of this group of patients.
12.8 Expert Commentary by
Dr. Lin
The author presents an excellent summary and results of their technique using minimally invasive
techniques. With a plethora of new devices and
technologies, we are progressively learning what
works for what areas, and this chapter outlining,
142
References
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among other techniques, plasma-based tightening
brings us closer to more widespread adoption
of these new technologies for rejuvenation of the
neck.
References
[1] Sterodimas A, Nicaretta B, Boriani F. composite face lifting:
the combination of stromal enriched lipograft with face
minilift and upper and lower blepharoplasty: a review of 210
cases. Ann Plast Surg. 2020; 85(6):e20–e23
[2] Sterodimas A. Stromal enriched lipograft for rhinoplasty
refinement. Aesthet Surg J. 2013; 33(4):612–614
[3] Sterodimas A, Huanquipaco JC, de Souza Filho S, Bornia FA,
Pitanguy I. Autologous fat transplantation for the treatment
of Parry-Romberg syndrome. J Plast Reconstr Aesthet Surg.
2009; 62(11):e424–e426
[4] Sterodimas A, Boriani F, Nicaretta B, Pereira LH. Hand rejuve-
nation by stromal enriched lipograft. J Plast Reconstr Aesthet
Surg. 2018; 71(10):1507–1517
[5] Sterodimas A, Boriani F, Nicaretta B, Pereira LH. Revision
abdominoplasty with truncal liposculpting: a 10-year experience. Aesthetic Plast Surg. 2019; 43(1):155–162
[6] Sterodimas A, de Faria J, Nicaretta B, Boriani F. Autologous fat
transplantation versus adipose-derived stem cell-enriched lipografts: a study. Aesthet Surg J. 2011; 31(6):682–693
[7] Sterodimas A, de Faria J, Nicaretta B, Pitanguy I. Tissue engi-
neering with adipose-derived stem cells (ADSCs): current
and future applications. J Plast Reconstr Aesthet Surg. 2010;
63(11):1886–1892
[8] Sterodimas A, Boriani F, Magarakis E, Nicaretta B, Pereira LH,
Illouz YG. Thirtyfour years of liposuction: past, present and
future. Eur Rev Med Pharmacol Sci. 2012; 16(3):393–406
[9] Gentile RD, McCoy JD. Pulsed and fractionated techniques for
helium plasma energy skin resurfacing. Facial Plast Surg Clin
North Am. 2020; 28(1):75–85
[10] Doolabh V. A single-site postmarket retrospective chart
review of subdermal coagulation procedures with renuvion.
Plast Reconstr Surg Glob Open. 2019; 7(11):e2502
[11] Stero dimas A. Ad ipose stem cell engineering: clinical appli-
cations in plastic and reconstruc t ive surgery. In: Illouz YG,
Sterodimas A, eds. Adipose Stem Cells and Regenerative
Medicine. Berlin: Springer-Verlag; 2011:165 – 179
[12] Sterodimas A. Tissue engineering with adipose-derived stem
cells (ADSCs) in plastic and reconstructive surgery: current
and future applications. In: Di Giussepe A, Shiffman M, eds.
New Frontiers in Plastic and Cosmetic Surgery. Philadelphia,
PA: The Health Sciences Publisher; 2015:3–11
[13] Pereira LH, Sterodimas A. Long-term fate of transplanted
autologous fat in the face. J Plast Reconstr Aesthet Surg.
2010; 63(1):e68 – e69
[14] Sterodimas A, de Faria J, Nicaretta B, Papadopoulos O, Papal-
ambros E, Illouz YG. Cell-assisted lipotransfer. Aesthet Surg J.
2010; 30(1):78 – 81
[15] Gentile P, Sterodimas A, Calabrese C, et al. Regenerative appli-
cation of stromal vascular fraction cells enhanced fat graft
maintenance: clinical assessment in face rejuvenation. Expert
Opin Biol Ther. 2020; 20(12):1503–1513
[16] Illouz YG, Sterodimas A. Conclusions and future directions.
In: I llouz YG, Sterodimas A, eds. Adipose Stem Cells and
Regenerative Medicine. Berlin: Springer-Verlag; 2011:273–
276
[17] Sterodimas A. The role of stem cells in body contouring. In:
Theodorou S, Chia C, eds. Liposuction & Emerging Technologies in Body Contouring. New York, NY: Thieme; 2018
[18] Sterodimas A, De Faria J, Correa WE, Pitanguy I. Tissue engi-
neering in plastic surgery: an up-to-date review of the current literature. Ann Plast Surg. 2009; 62(1):97–103
[19] Gentile RD. Renuvion/J-plasma for subdermal skin tightening
facial contouring and skin rejuvenation of the face and neck.
Facial Plast Surg Clin North Am. 2019; 27(3):273–290
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13 Neck Rejuvenation: Noninvasive Techniques
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Mathew N. Nicholas, Sara R. Hogan, Michael S. Kaminer, and Jeffrey S. Dover
Abstract
Noninvasive neck rejuvenation treatments can
make significant di
less recovery time and less risk of adverse effects
when compared to surgical approaches. The choice
of which noninvasive treatment to use requires
identifying individual patient concerns. Patient
concerns can be divided into five distinct categories: (1) dyschromia, (2) horizontal necklines,
(3) platysmal banding, (4) skin laxity, and (5) submental fullness. Dyschromia is largely caused by
ultraviolet radiation exposure. It can be targeted
with cosmeceuticals, chemical peels, intense
pulsed light, and various nonablative lasers. Horizontal necklines are caused by a combination of
skin laxity, underlying fascial attachments, and
downward pull of the platysma. Neuromodulators,
fillers, and laser and energy-based devices can
work in combination to target these causes. Platysmal banding results from the chronic contraction
of the platysma muscle in the setting of increasing
skin laxity. Neuromodulators are the primary noninvasive treatment; however, multiple different
techniques in using them have been described.
Skin laxity can be mild, resulting in rhytids and
wrinkling, or severe, creating jowls and submental
sagging. Fillers and energy-based devices, including
microfocused ultrasound with visualization, monopolar capacitive-coupled radiofrequency, and radiofrequency microneedling target more severe
laxity, while chemical peels, dermarolling or microneedling without radiofrequency, and platelet-rich
plasma can target more mild laxity. Submental
fullness is a common patient concern and more
resistant to improvement through exercise and diet.
Deoxycholic acid injections, cryolipolysis, energybased devices, and laser lipolysis all work by
decreasing subcutaneous fat with different mechanisms of action. In this age of numerous noninvasive
techniques, a combination of techniques is used to
target different patient concerns and optimize
outcomes. In this chapter , we describe currently
available noninvasive techniques and illustrate our
approach to tailored treatments for an individual
patient.
Keywords: neuromodulators, lasers, energy-based
devices, fillers, deoxycholic acid, cryolipolysis
fferences for patients and have
Key Points
●
Identifying specific patient concerns guides
appropriate noninvasive neck rejuvenation
treatment.
●
Patient concerns can be categorized as dyschromia, horizontal necklines, platysmal banding, skin
laxity, and submental fullness.
●
Typical noninvasive techniques require a combination of multiple different treatments to target
different patient concerns and enhance results.
13.1 Introduction
The demand for noninvasive cosmetic procedures,
including neck rejuvenation, increases each year.
The five key criteria of a youthful neck appearance
include the following: (1) a clear inferior mandibular border, (2) a subhyoid depression, (3) visible
thyroid cartilage bulge, (4) visible anterior sternocleidomastoid border, and (5) a cervicomental angle between 105 and 120 degrees.
ages, these criteria are lost. Available noninvasive
neck rejuvenation treatments can make significant
differences for patients with less recovery time
and less risk of adverse effects when compared to
surgical approaches. This chapter provides a comprehensive review of noninvasive neck rejuvenation techniques and illustrates our approach to
tailored treatments for an individual patient.
2
As the neck
13.2 The Aging Neck
The extent of skin aging is dictated by both intrinsic factors, such as ethnicity, anatomical variations,
and hormonal changes, and extrinsic factors including lifestyle, smoking, and ultraviolet radiation
(UVR) exposure.
first noted as this is more closely associated with
UVR exposure, regardless of age.
posure contributes to uneven pigment distribution
and the development of ephelides, solar lentigines,
and telangiectasias.
strongly associated with increasing age. Skin aging
is associated with fragmentation of collagen, resulting in poor fibroblast attachment and, consequently, fibroblast collapse. Collapsed fibroblasts
produce lower amounts of collagen and increased
3
Pigmentary changes are often
4
Chronic UVR ex-
5
Rhytids, meanwhile, are more
1
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amounts of collagen-destroying enzymes, expediting the aging process.
laxity of the skin and subsequent formation of rhytids and jowls. Aside from the skin, other anatomical changes occur with age, including subcutaneous
and subplatysmal fat accumulation, formation of
platysma muscle bands and horizontal necklines,
digastric muscle ptosis and hypertrophy, as well as
submandibular salivary gland ptosis and atrophy.
The combination of all of these changes over time
drives the need for neck rejuvenation.
6
Overall this process leads to
7,8
13.3 Patient Considerations,
Indications, and Contraindications
Recognizing patients appropriate for noninvasive
neck rejuvenation first requires a proper physical
examination. Evaluation of the patient starts with
identifying the patient’s greatest concern(s),
whether it be skin dyschromia, laxity, submental
fullness, or prominence of vertical or horizontal
necklines. During evaluation, the patient should sit
upright in neutral alignment and be given a mirror
to allow them to point out their personal concerns.
Note should be taken of color or texture changes of
the skin. Skin laxity and jowl appearance should
be examined at rest and during head and neck
movement. Palpation should be per formed to estimate subcutaneous fat volume and identify any
hypertrophied digastric muscles. Ptotic submandibular salivary glands or lymphadenopathy
should be noted given their contribution to submental fullness.
observed in younger patients with active muscle
contraction, evaluation of necklines should be
done at rest wit h both fronta l and lateral views.
Patient expectations need to be addressed during
the evaluation. Targeting patient concerns involving deeper anatomical structures including the
digastric muscles, submandibular salivary glands,
and the subplatysmal fat are contraindicated for
noninvasive neck rejuvenation a s these requir e
more invasive techniques.
8
Since platysmal bands can be
13.4 Which Technique to Use
and Why?
Patient concerns regarding the neck can be categorized into five distinct categories: dyschromia, horizontal necklines, platysmal banding, skin laxity,
and submental fullness. Identifying and prioritizing
patient concerns will help guide the choice of noninvasive treatment.
13.4.1 Dyschromia
Dyschromia or uneven skin pigmentation in the
aging neck is due to the presence of melanin, in
the form of ephelides or solar lentigines; vascular
changes from prominent telangiectasias; or hypopigmentation secondary to photodamage and loss
of collagen.
may predominate, neck dyschromia is often due to a
combination of the aforementioned factors. Poikiloderma of Civatte is a pigmentary/vascular condition
of the neck and upper chest caused by photodamage
and is characterized by hyperpigmentation, hypopigmentation, atrophy, and increased vascularity.
Dyschromia is treated similarly in the neck as in
other areas of the body, with one important distinction. Compared to the face, the skin of the neck is
thinner and contains less pilosebaceous units. These
features render neck skin more susceptible to scar
formation. As such, noninvasive techniques should
be administered with less aggressive settings.
5
Although a single pigmentary change
Cosmeceuticals
Cosmeceuticals were originally defined as “something in between a drug and a cosmetic” in 1984.
Cosmeceuticals are designed to address aesthetic
issues in skin not needing a medical prescription,
and often work in tandem with topical prescription medications. Demand for cosmeceuticals is
continuously increasing, with antiaging skin care
products accounting for over half of available skin
care cosmeceuticals.
shown that cosmeceuticals create significant neck
antiaging effects.
clude retinoids, alpha-hydroxy acids, antioxidants,
depigmenting agents, peptides, and physical and
chemical sunscreens.
10
A number of studies have
11,12,13,14
These products often in-
Chemical Peels
A number of chemical peels target dyschromia and
pigmentation. Chemical peels, such as Jessner or 70%
glycolic acid and 40% trichloroacetic acid, have been
studied in improving neck pigmentation.
concentrations of chemical peels should be used
with caution given the neck’s increased risk of scarring. The addition of lightening agents, such as in
modified Kligman’s formula, may also increase the
benefits of peels tha t target pi gmenta tion.
15,16
17
Higher
9
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