The aging neck is a complicated, difficult to treat area often requiring a combination of treatments for noninvasive rejuvenation. The interplay of the neck subunits, as outlined in the recent article by Friedman and colleagues, requires multiple combination treatments, including fat removal, augmentation of deficient bony prominences, relaxation of hyperkinetic muscles, tissue tightening, suture anchoring, skin resurfacing, and treatment of dyschromia.

Horizontal neck lines of a woman in her 20’s.

Horizontal neck lines are linear etched lines or furrows that commonly appear at a young age and are not caused by the aging process. The anatomy of the neck and the manner in which it bends contributes to their development at an early age. It is hypothesized that variable adipose tissue thickness and fibromuscular bands contribute to deepening of these lines in overweight patients. The widespread use of cell phones, laptops, and tablets has increased their prevalence and this has become one of the most common concerns of patients aged under 30 years in my clinic.

Various treatments have been recommended for neck rejuvenation, including hyaluronic acid and dilute calcium hydroxylapatite. In my experience, neither of these treatments adequately resolves the horizontal neck lines, and more importantly, prevents them from reoccurring. In addition, given the variability in skin and adipose thickness in the anterior neck, side effects including lumps, irregular correction, and the Tyndall effect, are common, particularly with incorrect choice of filler and injection depth.

The fibromuscular bands along the transverse neck lines pose one of the complexities in treatment with injectable filler. I have had significant improvement in the aesthetic outcome of my patients by using subcision along the transverse bands extensively prior to injection with hyaluronic acid fillers. The subcision is done with a 27-gauge needle to release the fibrous bands that tether the tissue down. If a patient has excess adipose tissue on either side of the bands, injectable fillers often do not improve the appearance of the lines and can make the neck appear heavier. The use of subcision followed by one to six treatments of deoxycholic acid in the adjacent adipose tissue prior to injection with a filler will help even out the contour of the neck, decrease adipose tissue bulges, release the fibrous bands, and fill the lines properly.

Working from home and on handheld devices has increased the appearance of neck lines in young populations. Despite the vast array of treatments in the aging neck, none have been very successful for this particular problem in the young. We need an improved understanding of these lines and better studies to investigate treatment options and long-term correction.

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