The picture of aging and rejuvenation of the neck area with injections of botulinum toxin type A

Visible signs of neck aging – the result of the combined effects of photo- and chronoaging. In order to solve the set aesthetic problem, it is important for the practitioner to know what processes lead to the appearance of imperfections, to correctly and comprehensively assess the condition of each patient, taking into account his goals and expectations, and based on the above points, suggest appropriate methods of anti-aging therapy.

In this article estet-portal.com Dr. Souphiyeh Samizadeh explains the pathophysiological processes leading to neck aging, talks about clinical criteria for determining the degree of aging and the use of botulinum toxin type A for neck rejuvenation.

• Pathophysiology of neck aging
• Evaluation criteria and clinical picture of neck aging
• Neck rejuvenation with botulinum toxin type A preparations
• Techniques for injecting botulinum toxin into the neck

Pathophysiology of neck aging

It is believed that the decrease in elasticity and flabbiness of the skin are the result of natural age-related changes:

• decrease in the proliferative capacity of skin cells;
• synthesis of collagen matrix in the dermis;
• enhanced expression of enzymes that break down the collagen matrix;
• decrease in elastin gene expression;
• oxidative damage.

These factors reduce the ability of the skin to self-regenerate and lead to a decrease in the amount of collagen in the skin, as well as structural changes in its fibers – thickening and chaotic arrangement.

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Sunlight-induced photodamage increases the degradation of the dermal matrix and reduces the effectiveness of dermal repair mechanisms.

Over time, the platysmal muscle complex begins to pull the tissues of the neck and face down, and a decrease in the tone of the subcutaneous muscle of the neck leads to a loss of clarity of the chin and the line of the lower jaw, as well as the formation of jowls.

Enlargement and ptosis of the submandibular glands – a natural part of the aging process, especially pronounced in thin patients. In combination with the descent of the hyoid bone and larynx, this leads to a change in the angle between the neck and the lower jaw, and the radial and horizontal wrinkles of the neck become deeper.

Fig. 1: classic signs of neck aging, including: a) vertical fibrous bands; b) horizontal bands; c) fullness of the central part of the neck due to the protrusion of the subplatysmal fat pack

Earlier it was thought that bands of platysma – the result of loss of muscle tone and changes in the skin. However, they appear due to the activity of the subcutaneous muscle of the neck, which pulls the skin along with it.

Loss of platysmal muscle tone contributes to the protrusion of the subplatysmal fat pad and the appearance of fullness in the central part of the neck. A large submental fat pack protrudes behind or between the two free borders of the subcutaneous muscle of the neck. In the process of aging, the fibers of the subcutaneous muscle of the neck are separated from the deep planes and become thinner, which also visually enhances aging.

Read also: Combined approach to neck rejuvenation: HA and botulinum toxin injection technique

The retaining ligaments that keep the platysma close to the hyoid and mandible also weaken over time. In general, vertical and horizontal neck wrinkles appear around the age of 40 and earlier, for example, in active patients with low levels of body fat. Horizontal neck wrinkles in young patients also appear due to frequent use of gadgets.

Evaluation criteria and clinical picture of neck aging

The following visual criteria are used to assess the youthfulness of the neck:

• clear line of the lower jaw (the lower border of the lower jaw is clearly defined from the chin to the mandibular angle, there are no jowls);
• sublingual depression (makes the neck visually long and thin);
• visible contour of the thyroid cartilage;
• visible anterior border of the sternocleidomastoid muscle;
• Angle between neck and lower jaw 105–120 degrees.

Read also: Neck rejuvenation with thread lifting

The classic picture of neck aging includes:

• Vertical bands;
• horizontal bands;
• fullness in the central part of the neck due to the protrusion of subplatysmal fat.

Neck rejuvenation with botulinum toxin type A

With the right choice of the patient, botulinum toxin type A provides effective therapy for neck wrinkles (vertical bands and horizontal lines), as well as deformities of the contour of the lower third of the face. BoNT-A preparations are very good at eliminating single strands of platysma.

Read also: Combined approach to neck rejuvenation: HA and botulinum toxin injection technique

Since the subcutaneous muscle of the neck plays a decisive role in the mechanism of neck aging, "pulling" down the skin and structures of the lower third of the face, the use of botulinum toxin type A for the rejuvenation of this area is fully justified. Through denervation and neuromodulation of platysma, botulinum toxin reduces:

• muscle tension;
• severity of vertical bands;
• severity of horizontal neck wrinkles.

In addition to this, botulinum toxin therapy of the neck leads to the identification of the contour of the lower jaw.

The activity of platysma, combined with the depressant action of the muscles that lower the corners of the mouth, leads to a downward displacement of the wrinkles of the corners of the mouth.

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The main indication for the use of BoNT-A in the neck area – muscle hyperactivity. Therefore, botulinum toxin preparations work best in patients with hyperactive muscles and minimal or no skin laxity.

Ineffective botulinum therapy will be in case of:

• excessive flabbiness of the skin;
• severe lipodystrophy;
• hypertrophic submandibular glands.

Injection of botulinum toxin type A to change the tone of other depressor muscles in the lower third of the face helps to reduce the appearance of wrinkles and lines, as well as improve the definition of the line of the lower jaw.

Aggressive therapy and overcorrection of the subcutaneous muscle of the neck should be avoided. Like any weakened/paralysed muscle, it can atrophy. Atrophy of the platysma inevitably entails a weakening of the support of the lower third of the face and neck, which accelerates aging in the long term.

Techniques for injecting botulinum toxin preparations into the neck

Neck rejuvenation with BoNT-A was first described by Brant and Bellman in 1998. The authors worked on the elimination of platysma strands and received an additional effect – improvement of the contour of the lower jaw. Nefertiti's Technique presented by Levy allows you to:

• provide lifting and make the angle and border of the lower jaw more clear;
• raise the corners of the mouth;
• hide the skin of the contour of the lower jaw.

Fig. 2: Nefertiti lifting technique presented by French doctor Levy

By understanding and taking into account the anatomy of the platysma, it is possible to make a correct diagnosis and adjust the injection into the target muscles.

Potential complications of botulinum toxin type A depend on the injection technique and include:

• muscle pain or discomfort in the neck;
• difficulty lifting head from a lying position;
• headaches;
• hoarseness;
• difficulty swallowing;
• dry mouth;
• disorders of chewing and speech function;
• hematoma/ecchymosis.

Proper technique and low doses of the toxin are essential to reduce the risk of complications, including dysphagia.

To obtain optimal results from non-surgical neck rejuvenation, practitioners often need to combine different correction methods. Botulinum toxin type A injections in the neck area have shown good results, but their long-term effect has not been evaluated in studies.

Adapted from Aesthetics.

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