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13.4 Which Technique to Use and Why?
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Lasers and Energy-Based Devices
Intense pulsed light (IPL) targets vascular and pigmented lesions, and thus is quite effective at treating
poikiloderma of Civatte, with over 80% of patients in
one study showing a marked 75 to 100% clearance
after three or fewer treatments spaced 1 month
18,19
apart.
bruising, as well as “striping” and persistent hypopigmentation due to imprecise technique or inappropriate energy settings, res pective l y.
laser and 532-nm potassium titanyl phosphate
(KTP) and lithium triborate (LBO) lasers are effective in improving the appearance of dilated blood
vessels but are not as effective at targeting pigmented lesions.
ing the 1,927-nm thulium laser, 1,540-nm erbiumglass fiber laser, 1,550-nm erbium-glass fiber laser,
and Q-switched 1,064-nm Nd:YAG (neodymium:yttrium aluminum garnet) laser can also address neck
dyschromia.
lasers selectively damage the dermal vasculature in
poikiloderma in two ways. First, these wavelengths
target water, a main component of blood, likely causing subsequent microvascular destruction. Second,
microthermal zones of injury within the dermis also
likely affect dermal vasculature.
1,550-nm laser wavelength, which targets deeper
dermal structures, with the 1,927-nm wavelength,
which targets the epidermal and superficial dermal
structures, is thus particularly effective in treating
dyschromia, hyperpigmentation, and texture. The
Fraxel Re:Store DUAL (Solta Medical, Bothell, WA)
utilizes both these wavelengths and is an increasingly popular treatment choice for poikiloderma of
Civatte. Typically, three or more treatments, spaced
4 to 6 weeks apart, are needed for notic eable resul ts.
Patients should be counseled on common side
effects with nonablative fractional photo thermol ysis,
such as swelling, erythema, discomfort, and mild
scaling. Fractional photothermolysis may also be
combined with IPL, Q-switched, or picosecond lasers
to achieve even better pigmentary improvement in
the treatment of poikiloderma of Civatte.
Side effects include swelling, erythema, or
18,19
Vascular lasers such as the 595-nm pulsed dye
20,21
Nonablative fractional photothermoly sis, includ-
22,23,24
Behroozan et al sugge st that the se
22
Combining the
attachments, and the downward pull of the
platysma.
25
Horizontal necklines are found in normal physiology and can be observed at any age, including younger patients at rest. As the neck ages,
horizontal necklines become more prominent. A
validated 5-point assessment Transverse Neck Lines
Scale (▶ Table 13.1) can be used when evaluating a
patient for horizontal necklines, with values ranging
from none (no transverse necklines) to extreme
(noneffaceable transverse neck furrows with redundant skin; ▶ Fig. 13.1).
25
Neuromodulators
When injected directly into horizontal necklines,
neuromodulators relax the downward pull of the
platysma. Neuromodulators do not address skin
laxity and thus when administered alone can be
suboptimal in treating horizontal necklines. Botulinum toxin A injections of 1 to 2 units spaced 1 to
1.5 cm apart along the lines may create an improvement and satisfaction rate of up to 50%.
From our clinical experience, injection of botulinum toxin A along the platysma bands may also
create a small effect on horizontal lines. Yet, when
combined with other methods such as dermal fillers, botulinum toxin A can play a successful role in
significantly decreasing the horizontal neckline
27
size.
Fillers
Dermal fillers lessen the appearance of horizontal
necklines by addressing volume loss. Calcium hydroxylapatite (Radiesse; Mer z North America,
Inc., Raleigh, NC) diluted 1:1with 1% lidocaine can
be injected between the dermal and subde rmal
Table 13.1 Five-point Allergan Transverse Neck Lines
Scale as adapted by Jones et al
0 None: no transverse necklines
1 Minimal: superficial transverse necklines
2 Moderate: moderate, effaceable transverse
necklines
25
26
13.4.2 Horizontal or Transverse
Necklines
Horizontal or transverse necklines are caused by
a combination of skin laxity, underlying fascial
3 Severe: deep, noneffaceable transverse
necklines
4 Extreme: noneffaceable transverse neck
furrows with redundant skin
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Fig. 13.1 A patient with prominent horizonal necklines showing (a) frontal and (c) la teral pretreatment views and (b) frontal
and (d) lateral posttreatment views after one treatment of Belotero hyaluronic acid fillers injected intradermally to horizontal
necklines followed by 6 mL of hyperdiluted Radiesse calcium hydroxylapatite injected subdermally 4 weeks later.
(Reproduced with permission of Sara Hogan, MD.)
junction along the horizont al necklines or
throughout the neck in a fanlike manner with a
25- or 27-gauge cannula.
28,29
Soft malleable hyaluronic acid fillers (Belotero Balance, Merz North
America, Inc.; Belotero Soft; Merz North America,
Inc.; Restylane Silk, Q-Me d AB, Uppsala, Sweden;
Teosyal RHA 2; TEOXANE SA, Geneva, Switzerland; Juvederm Volbella XC; Allergan, Inc., Dublin,
Ireland) injected in the dermal plane have demonstrated continued efficacy of up to at least 36
weeks in the literature.
27,30,31,32
Patients should
be counseled on potential side effects of filler
injection, including redness, itching, bruising,
swelling, and, rarely, nodule formation.
30
Nodule
formation is most often due to superficial placement of fillers.
Lasers and Energy-Based Devices
Ablative fractional CO2laser has been used to significantly improve the appearance of horizontal necklines, with results lasting 1 year posttreatment after
a single treatment. The therapeutic window is narrow, however, bringing to question whether benefit
outweighs the risk of scarring.
tional 1,440- or 1,550-nm lasers may be considered
an alternative approach to decrease the risk of scarring. Laser treatment may also be combined with
neuromodulators, which are typically administered
1 week beforehand.
34
Microfocused ultrasound with visualization
(MFU-V) and monopolar capacitive-coupled radiofrequency (MRF) can decrease the appearance of
33
Nonablative frac-
148
13.4 Which Technique to Use and Why?
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horizontal necklines by inducing neocollagenesis
and improving skin laxity.
27,29
Both MRF and MFU-V
can be combined safely with subsequent same-day
dermal filler use for neck rejuvenation. In one study,
MFU-V (Ultherapy; Ulthera, Inc., Mesa, AZ) with
subsequent same-day injection of diluted calcium
hydroxylapatite (Radiesse; Merz North America,
Inc.) decreased the Transverse Neck Lines Scale
scores from an average of 2.6 at baseline to 1.3 at 90
days posttreatment.
29
13.4.3 Platysmal Banding
Vertical necklines are caused by chronic contraction of the platysma muscle in the setting of increasing skin laxity.
35
Younger patients are able to
create platysmal bands with active contraction,
which disappear at rest. When evaluating a patient
for platysmal banding, a validated 5-point Dynamic Platysmal Band Photonumeric Assessment Scale
(▶ Table 13.2) can be used with scores ranging
from no relevant prominence of platysmal bands
to very severe prominence of platysmal bands
(▶ Fig. 13.2).
35
Neuromodulators
Brandt and Bellman first described botulinum toxin A as a treatment for platysmal bands in 1998.
Neuromodulators are a safe and noninvasive
approach to decrease platysmal bands; however, the
treatment effect is temporary lasting 2 to 4 months.
Early studies endorsed high doses of botulinum toxin A, with up to 250 of onabotulinum-equivalent
units being used. The most recent consensus,
however, is that no more than 100 units be injected into the platysma given the potential for
side effects.
achieved with doses of as little as 28 to 36 units
Table 13.2 Five-point Dynamic Platysmal Band Photonumeric Assessment Scale as adapted by Geister et al
0 No relevant prominence of platysmal bands
1 Mild prominence of platysmal bands
2 Moderate prominence of platysmal bands
3 Severe prominence of platysmal bands
4 Very severe prominence of platysmal bands
37,38
In fact, excellent results can be
35
of onabotulinum-equivalent units. Safe injection
technique involves pinching the skin and underlying platysmal bands upward and away from other
neck structures. Two to three onabotulinum toxinequivalent units are then injected every 1 to 1.5 cm
vertically along each band.
39
Studies show a mean
2-point improvement on the Dynamic Platysmal
Band Photonumeric Assessment Scale by day 14,
which decreases to 1.2 points by 3 months.
most common side effect is bruising. Prolonged
dysphagia and neck weakness are most frequently
seen in doses higher than 100 units, but can still occur rarely at lower doses.
38,40
When combined with
lasers, neuromodulators may be administered the
same day as vascular and pigment lasers, 1 week
after nonablative fractional lasers, and 3 weeks
after ablative fractional lasers.
34
The Nefertiti lift targets the platysma to redefine
the jaw line while also improving the appearance
of the neck. First described by Levy, the Nefertiti lift
involves injecting 30 to 40 total onabotulinumequivalent units along the lower mandible and the
upper platysmal bands. The resulting release of the
downward pull from the platysma muscle improves
the sight of platysmal bands while also contouring
the lower face.
41
The original technique addresses
only posterior platysma fibers, creating mandibular
contour improvement in mostly lateral views only.
36
The modified Nefertiti lift reported by De Almeida et
al also targets anterior platysma fibers and incorporates two lines of mandibular injections points along
the entire mandible, improving mandibular contour
in both lateral and anterior views.
42
Finally, the Microbotox technique, first described
by Wu in 2015, involves approximately 150 injections of botulinum toxin A into the superficial dermis in a gridlik e pattern across the anterior neck and
mandible. When compared to the Nefertiti lift, the
Microbotox technique is less effective at targeting
platysmal bands but may play a better role in targeting jowls and soft-tissue laxity.
43
13.4.4 Skin Laxity
Laxity in the lower face and neck both contributes
to the aging neck. Mild forms of laxity present as
rhytids and wrinkles. More severe forms of laxity
contribute to jowls and submental sagging with the
formation of a convex cervicomental angle.
validated Fasil Face and Neck Laxity Grading Scale
is used to evaluate laxity in the upper, middle, and
lower face and upper neck.
45
▶ Table 13.3 contains
40
The
44
The
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Fig. 13.2 A 58-year-old woman showing (a) frontal and (c) lateral views of the platysmal bands pretreatment and
(b) frontal and (d) lateral posttreatment views 2 weeks following botulinum toxin injections. (Adapted from Nahai F,
Nahai F, ed. The Art of Aesthetic Surgery: Principles and Techniques. 3rd ed. New York, NY: Thieme; 2020.)
a modified version of the scale to highlight the clinically relevant portions for neck rejuvenation.
Dermal Fillers
Dermal fillers stimulate collagen production to decrease skin laxity. Calcium hydroxylapatite (Radiesse,
150
Merz North America, Inc.), when hyperdiluted with
1% lidocaine and injected into the neck and décolletage, shows histopathologic evidence of increased
collagen, elastin, and angiogenesis, even 7 months
postinjection.
two to three sessions spaced 1 to 2 months apart for
maximum results in biostimulation and skin tight-
46
Consensus recommendations advise
13.4 Which Technique to Use and Why?
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ening lasting over 18 months.47Dilution varies with
patient skin thickness, with older patients typically
requiring greater dilution. For the neck in particular,
a dilution of 1:2 or 1:4 is satisfactory for most
patients. One syringe per session is generally recommended. The filler is in ject ed by cannula vi a retrojection in a fanlike manner at each of three to five
entrance points or alternatively with serial punctures using a needle creating short horizonal lines
around the neck.
47
Alternatively , poly-L-lactic acid
can be used in a similar fashion to stimulate neocollagenesis and has good evidence for treating neck
skin laxity. A single treatment can create physiciannoted improv ement in neck laxity 60 days posttreatment in 81 to 100% of patients.
48
and laser resurfacing, where potential side effects
and subsequent recovery time may be worrisome
to patients.
The first MRF device (Thermage CPT; Solta Medical, Haywood, CA) was Food and Drug Administration (FDA) approved for periorbital rhytids in 2002
and subsequently FDA approved for all rhytids in
2005. MRF uses electric current transmitted
through the neck to create a broad thermal coagulation zone from the resistance of the tissues
affected. The amount of energy and resulting heat
increases with increasing current, tissue resistance,
and time of exposure. The system uses superficial
cryogen cooling alongside the generated current to
create dermal temperatures of 65 to 75 °C while
preventing the epidermis from rising above 40 °C
Lasers and Energy-Based Devices
MFU-V and MRF provide another option to traditional methods of skin tightening such as surgical
Table 13.3 Modified Fasil Face and Neck Laxity Grading Scale as adapted by Alhaddad et al
Class 0 Class 1 Class 2 Class 3 Class 4 Class 5
Lower
face
Jowls Absent Slightly
noticeable
and thus preventing epidermal damage. Clinical improvement in upper neck skin laxity is reported in
▶ Table 13.4. Thermage uses a stamping motion
technique, creating short pulses of energy at each
Protruding
forward
Protruding
forward and
downward
45
Forward
protrusion
with
downward
sagging
Forward sagging
and lateral loss of
definition in the
neck
Upper
neck
Table 13.4 Clinical results using monopolar radiofrequency (Thermage) in neck rejuvenation
Study Design Energy
Alster
Tanzi
Fritz
et al
50
51
Platysma
bands
Horizontal
bands
Prospective,
nonrandomized
Prospective,
randomized
Absent Absent Slightly
Absent Absent Absent Slightly
level
settings
74–134
J/cm
85–135
J/cm
No. of
patients
20 6 mo 1 85% of patients had improvement
2
20 4 mo 1 or 2
2
noticeable
Follow-up
after final
treatment
Prominent Sagging Sagging to the
noticeable
No. of
treatments
treatments
Prominent
Significant outcomes
Average physician-reported
improvement score of 1.27, where
0=<25%, 1=25–50%, 2 = 50–75%,
3 = >75% improvement
Physician reported improvement
1 treatment: 11% overall
improvement
2 treatments: 15% overall
improvement
point where
bands or folds
are no longer
distinguishable
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Neck Rejuvenation: Noninvasive Techniques
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location (▶ Fig. 13.3). Other MRF devices have since
been created and rely on different delivery methods
such as a continuous motion technique (Exilis, BTL
Aesthetics, Prague, Czech Republic; Pelleve, Ellman
International, Inc., Oceanside, NY) or the use of a
subcutaneous probe to completely bypass the epidermis and heat the dermis from underneath
(ThermiTight, ThermiAesthetics, Southlake, TX).
49
In 2012, MFU-V (Ultherapy, Ulthera, Inc.) gained
FDA approval for the noninvasive lift of skin on the
neck and under the chin. MFU-V uses focused
Fig. 13.3 A patient presenting with neck skin laxity showing (a) pretreatment, (b) 2 months posttreatment, and (c) 4
months posttreatment views following one treatment with Thermage. (Adapted from Papel I, Frodel J, Holt R et al., ed.
Facial Plastic and Reconstructive Surgery. 3rd ed. New York, NY: Thieme; 2009.)
ultrasound waves to create 1 mm
lation zones of 65 °C up to 8 mm below the surface
of the skin. By combining the technology with visualization, the provider can image the tissue and
provide heat at the exact intended depth. The coagulation zones immediately alter the targeted collagen and stimulate neocollagenesis to improve
skin elasticity and firmness over time while completely avoiding damage to the epidermal layer.
Clinical results with MFU-V are summarized in
▶ Table 13.5 (▶ Fig. 13.4).
3
thermal coagu-
52
Table 13.5 Clinical results using microfocused ultrasound with visualization in neck rejuvenation
Study Design Device No. of
Kerscher
52
et al
Kerscher
53
et al
Werschler
and
Werschler
Oni et al
55
56
Prospective,
nonrandomized
Prospective,
nonrandomized
Prospective,
nonrandomized
Prospective,
nonrandomized
Ultherapy 22 24 wk 1 Gross skin elasticity
Ultherapy with
calcium
hydroxylapatite
filler
Ultherapy 20 1 y 1 treatment,
Ultherapy 103 90 d 1 65.6% of patients
patients
9 48 wk 1 89% of patients with ≥ 1
Follow-up
after final
treatment
No. of
treatments
2 passes
Significant outcomes
(Cutometer
measurement)
significantly improved
compared to baseline
improvement in Mer z
Aesthetic Scale
95% of patients had
physician- and subjectrated improvement
95% of patients were
satisfied or very
satisfied
reported improvement
58.1% of patients had
physician-reported
improvement
54
152
13.4 Which Technique to Use and Why?
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Fig. 13.4 A patient presenting with neck skin laxity showing (a) pretreatment and (b) 90 days posttreatment views
following one treatment with Ulthera. (Adapted from Few JW Jr. The Art of Combining Surgical and Nonsurgical
Techniques in Aesthetic Medicine. 1st ed. New York, NY: Thieme; 2018.)
In 2019, Alhaddad et al published a prospective,
randomized, evaluator-blinded, split-face clinical
trial to compare the efficacy and safety of MFU-V
and MRF.
45
The primary end point was a difference
in the Fasil Face and Neck Laxity Grading Scale
(▶ Table 13.3).
44
Twenty patients had a single
treatment of MRF on one side of the face and neck
and a single t reatment of MFU-V on the other.
There was significant decrease in the Fasil Face
and Neck Laxity Grading Scale for both treatments
starting at day 30 posttreatment, which was maintained up to day 180 posttreatment. There was no
statistical difference between sides of the face and
neck treated with MRF compared to MFU-V,
although as noted by the authors, this study was
limited by the small sample size used. One patient
had mild erythema on day 30 posttreatment on
the MFU-V-treated side, but no erythema, edema,
contour irregularity, or bruising were noted at day
90 or 180 posttreatment in any patient. Although
not statistically significant, there was a statistical
trend toward a less painful experience with MRF as
reported by patients when compared to MFU-V.
45
comparison of MFU-V and MRF is summarized in
▶ Table 13.6.
The addition of radiofrequency energy with microneedling allows the delivery of ther mal energy
at controlled depths to stimulate neoelastogenesis
and neocollagenesis while supporting increased
absorption of topical products and skin remodeling
due to the mechanical needling effects. A number
of different radiofrequency microneedling (RFMN)
devices exist and vary in depth of penetration, needle material and diameter, use of insulated versus
noninsulated needles, use of monopolar or bipolar
energy, and ability to deliver consistent energy
throughout an entire treatment with real-time impedance monitoring.
59
RFMN has been studied
extensively for skin rejuvenation with excellent
60
results.
When compared to three sessions of
2,940-nm fractional Er:YAG (erbium-doped:yttrium
aluminum garnet) laser treatments administered at
1-month intervals, three sessions of RFMN delivered at the same time intervals to treat facial and
neck wrinkling produced significantly higher patient satisfaction rates.
61
It was theorized that
RFMN created deeper and broader microscopic
thermal zones, leading to increased efficacy in skin
tightening.
61
RFMN settings for greatest efficacy
include thermal energy delivered for 3 to 4 seconds at a temperature of 67 °C, 1.3 to 2 mm depth
of penetration, and applications spaced 3 to 4 mm
A
60
apart.
neck area.
Typically 50 insertions are used for the
62
A single treatment at these settings
yielded a 100% response rate in blinded evaluations of skin laxity and skin wrinkling of the neck
area 6 months posttreatment.
62
Pain can be the
most treatment-limiting side effect. Other side
153
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Table 13.6 Comparison of monopolar capacitive-coupled radiofreq uenc y and microfocused ultrasound with
visualization
Mechanism of
action
Invasiveness Noninvasive Noninvasive
Indications Mild to moderate skin laxity Mild to moderate skin laxit y
No. of treatments Usually one treatment Usually one treatment
Procedure length 30–90 min 60–90 min
Adverse effects Transient mild erythema, edema, burns,
Efficacy Comparable to MFU-V Comparable to MRF
Advantages May be less painful than MFU-V Depth can range from 1.5 to 4.5 mm, able to
Disadvantages Depth limited as it must transmit through
57,58
Monopolar capacitive-coupled
radiofrequency (MRF)
Tissue resistance-induced thermal
coagulation zone from current source
nerve damage/neuropathy, and scarring
possible
tissue, no visualization of area targeted, and
poorer results in high BMI patients and
patients who smoke
Microfocused ultrasound with visualization
(MFU-V)
3
thermal coagulation zones created by
1mm
focused ultrasounds
Transient mild erythema, edema, tingling, and
tenderness, nerve damage/neuropathy, and
scarring possible
visualize area affected with ultrasound, and
thermal coagulation zones can be more precise
Poorer results in high BMI patients and patients
who smoke
Durability of
results
Absolute
contraindications
Abbreviations: BMI, body mass index.
12–24 mo 12- to 18-mo treatment intervals for
Patients with cardiac pacemakers or other
active implants and pregnant women
effects for RFMN are mild and transient and include erythema, swelling, purpura, and postinflammatory hyperpigmentation.
60
Dermarolling, Microneedling,
Chemical Peels, and Platelet-Rich
Plasma
Other treatments for skin laxity exist, but target
mild laxity in the form of rhytids and wrinkling.
Studies examining the benefits of chemical peels
in neck dyschromia, namely, Jessner or 70% glycolic acid and 40% t richloroacetic acid peels, also
noted decreased wrinkling when used on the
15,16
neck.
Similar f indings were also seen with
maintenance (up to 24 mo in select populations)
Patients with cardiac pacemaker or other active
implants are candidates except over area of
implant, and pregnant women
three sessions of platelet-rich plasma injections
into the face and neck spaced 1 month apart,
with 52% of patients stating t heir wrinkles had
63
improved.
Dermarolling and microneedling
without radiofrequency can be used to treat textural change, with almost 90% of patients seeing
noticeable results after two treatments.
64
13.4.5 Submental Fat and Fullness
In the American Society for Dermatologic Surgery
2019 Consumer Survey on Cosmetic Dermatologic
Procedures, 73% of consumers were bothered by
excess fat under the chin and neck.
adipose tissue is less likely to respond to traditional
65
Submental
154
13.4 Which Technique to Use and Why?
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diet and exercise and thus, noninvasive submental
contouring can have profound effects on neck rejuvenation. Submental fat is divided into two compartments: subcutaneous or preplatysmal fat and
subplatysmal or postplatysmal fat. Nonsurgical
submental contouring typically targets subcutaneous fat alone as subplatysmal fat removal could
lead to concavity.
66
Patients with large am ounts
of sub platysmal fat, however, may not experience
significant improvement when using noninvasive
methods co mpared to more invasive, deeper
methods of fat removal. Furthermore, patients
should be examined for digastric muscle hypertrophy, subm andibular salivary gland ptosis, and
cervical lymphadenopathy, as these may be mistaken for submental fat and are not amenable to
noninvasive therapies.
8
Deoxycholic Acid
Deoxycholic acid was first FDA approved in 2015
for targeting moderate to severe submental fat.
Classically known at ATX-101, but now clinically
sold as Kybella in the United States and Belkyra in
Canada (Allergan Bio-pharmaceuticals, Inc, Westlake Village, CA), the drug is a synthetic compound
identical to endogenous deoxycholic acid, a secondary bile acid created in the intestine for emulsification of fat.
injections of 1 to 2mg/cm
like fashion causing adipocytolysis and removal of
excess submental fat.
spaced 1 to 3 months apart may be required for a
desired result to be noted. Patients with an active
67
ATX-101 is administered in multiple
2
under the chin in a grid-
68
Three to six treatments
submental infection should not be considered for
deoxycholic acid (▶ Fig. 13.5).
Clinical results of deoxycholic acid are summarized in ▶ Table 13.7. Commonly reported outcomes include a greater than 1 point improvement
in the Clinician-Reported Submental Fat Rating
Scale (CR-SMFRS), the Patient-Reported Submental
Fat Rating Scale (PR-SMFRS), or a combination of
the two when compared to baseline (▶ Table 13.8).
The first phase III clinical trial by Rzany et al in
2014 used a maximum of four treatments and both
1 and 2 mg/cm
2
concentrations were used with a
trend toward greater efficacy with the higher dose,
although the trial was not conducted to compare
the two doses.
the higher concentration of 2 mg/cm
mum of six treatments with excellent efficacy.
69
REFINE-1 and REFINE-2 trials used
2
and a maxi-
70,71
Although up to six treatments were allowed, post
hoc analysis from pooled trial data showed that significant improvements were achieved after only
two to four treatments.
72
In the Condition of Submental Fullness and Treatment Outcomes Registry
(CONTOUR) study, a prospective, multicenter, noninterventional study of 570 patients receiving submental deoxycholic acid injections, 25 and 30% of
patients who achieved their treatment goals did
not have improvement of greater than 1 point on
CR-SMFRS and PR-SMFRS, respectively.
73
Therefore,
patients can be satisfied with treatment even without reaching the end points used in clinical trials.
Side effects of deoxycholic acid are generally
mild to moderate in severity. Among the clinical
studies, nearly all side effects resolved by study
end. The most frequent side effects include pain,
Fig. 13.5 A patient presenting with submental fullness showing (a) pretreatment and (b) posttreatment views following
treatment with Kybella injections. (Adapted from Gerecci D, Perkins S. The graduated approach to surgical neck
contouring. Facial Plast Surg 2019;35(5):516–524.)
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% with ≥1
improvement on
%with≥ 1
improvement on
% with ≥1
improvement on
No. of
treatments
CR-SMFRS and
PR-SMFRS
PR-SMFRS
CR-SMFRS
Not reported
: 67.0%
2
Placebo: 32.4%
1 mg/cm
: 59.2%
2
Placebo: 23.0%
1 mg/cm
by28±5d
: 73.6%
2
2 mg/cm
: 65.3%
2
2 mg/cm
intervals
: 70.0%
2
Placebo: 18.6%
2 mg/cm
: 82.3%
2
Placebo: 38.5%
2 mg/cm
: 79.1%
2
Placebo: 36.2%
2 mg/cm
by28±5d
intervals
: 66.5%
2
Placebo: 22.2%
2 mg/cm
: 78.4%
2
Placebo: 37.8%
2 mg/cm
: 77.9%
2
Placebo: 34.5%
2 mg/cm
by28±5d
intervals
: 88.0% Not reported Not reported
2
2 mg/cm
by at least 1 mo
apart
Not reported
12 wk: 83.8%
12 mo: 80.7%
12 wk: 86.8%
12 mo: 90.4%
1–6, separated
by ~1 mo
Not reported
Out of patients who
Out of patients who
met treatment
goals: 70%
met treatment
goals: 75%
separated by on
average 8.9–16.7
Out of patients who
Out of patients who
wk between
did not meet
did not meet
treatments
treatment goals:
48%
treatment goals:
58%
(Continued)
156
Table 13.7 Clinical results using deoxycholic acid in the submental region
Dosage Follow-up
Study Design No. of
after final
treatment
patients
12 wk 1–4, separated
,
2
and 2 mg/
Placebo,
1 mg/cm
: 119
: 121
2
2
2 mg/cm
Placebo: 122
1 mg/cm
Multicenter,
randomized,
double-blind,
69
Rzany et al
2
cm
placebo
12 wk 1–6, separated
Placebo,
Placebo: 250
controlled
Multicenter,
REFINE-1:
2
2 mg/cm
: 256
2
2 mg/cm
randomized,
double-blind,
placebo
71
Jones et al
12 wk 1–6, separated
Placebo,
Placebo: 258
controlled
Multicenter,
REFINE-2:
2
2 mg/cm
: 258
2
2 mg/cm
randomized,
double-blind,
placebo
70
Humphrey et
al
5–7wk 1–6, separated
2
: 100 2 mg/cm
2
2 mg/cm
controlled
Single-center,
74,
Shridharani
single-arm,
open label
75
12 wk and
12 mo
2
: 165 2 mg/cm
2
2 mg/cm
Multicenter,
single-arm,
76
Beer et al
12 mo 1–5 treatment,
570 Not
open-label
Multicenter,
73
CONTOUR:
reported
single-arm,
open-label
Behr et al
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