Prediction of Treatment Outcomes for Neck Rejuvenation Utilizing a Unique Classification System of Treatment Approach Using a 1440-nm Side-Firing Laser

Prediction of Treatment Outcomes for Neck Rejuvenation Utilizing a Unique Classification System... Abstract Background The appearance of a youthful neck is lost with age causing excessive skin laxity, a loss of subcutaneous fat, prominence of platysmal banding, and jowling. In view of the success obtained with laser treatment for neck rejuvenation, the authors have recently taken an algorithmic approach to developing a 7-category classification system of the aging conditions throughout the anatomic spectrum of three areas: skin, fat, and muscle. This system will correlate with specific treatment options. Objective The objective of the study was to confirm the 7-category classification system and treatment approaches based on clinical outcome data for treatment of the mandibular and submandibular areas, specifically for skin tightening and laser lipolysis after a single 1440-nm laser treatment. Methods Patients were treated with a single treatment of PrecisionTX™ 1440-nm wavelength laser on their necks. Baseline and posttreatment photographs were taken and evaluated by 3 blinded reviewers using the Cervicomental Angle Scale (CAS). Results Subjects were rated grades II-III (2.9 ± 0.8) on average at baseline and grades I-II (1.3 ± 0.5) at follow-up. The average improvement was a mean score of 1.5 ± 0.07. Patients, 23/25 (92%), showed at least a 1 score improvement. Conclusions This study confirms a new minimally invasive treatment approach based on a unique classification system with no adverse events reported and high patient satisfaction. Level of Evidence: 4 The lower face represents one of the most prominent indicators of aging. A youthful neck appearance is defined by good skin tone, a well-defined cervicomental angle and mandibular border, without signs of platysmal banding and submental fat accumulation. With age, the skin will lose collagen and elastin causing excessive skin laxity, a loss of subcutaneous fat, prominence of platysmal banding, and jowling. Even in some youthful patients, fat accumulation occurs resulting in a lack of definition of the mandible and cervicomental angle.1 During the past 20 years, there has been a proliferation of technologies and devices for neck rejuvenation.1 Consequently, the question of how to treat the neck and what technique to employ when needed becomes important, with an ultimate aim of standardization. Review of our database of patients from our plastic surgery clinic revealed patterns of diagnosis and treatment. Our published report of the findings defines the characteristics of various patient types to develop a diagnostic approach to treatment options for neck rejuvenation. In this study the authors expand the classification and treatment scheme for neck rejuvenation, and recommend treatment approaches using the most recent advances. Intrinsic and extrinsic factors at progressive stages of life affect the neck and present as unwanted signs of aging. These effects are typically found in three anatomic layers, which include the skin, muscle, and fat layers. Loss of subcutaneous fat, prominence of platysmal banding, jowling along the mandibular border, and excessive skin laxity due to loss of collagen and elastin are common conditions that are treated. Enhancement of the aging neck has improved over the last 30 years with a trend toward less invasive procedures and smaller incisions. Lasers have traditionally improved skin surface, texture, and laxity in the face. Neck skin however, is more limited in its healing capacity from external insults. Previous to the development of a plethora of treatments for body sculpting and skin rejuvenation, a 6-category classification system was developed based on changes to the anatomical layers of the neck. The first class describes a youthful neck with a well-defined cervical mental angle, minimal submental fat, good skin and platysma tone. The second class represents laxity of the cervical skin without significant submental fat or platysmal banding. The third class contains a layer of subcutaneous fat, which is either genetic or acquired in need of removal. The fourth class describes platysmal banding and the fifth presents retrognathics. Lastly, class 6 are cases that contain a low hyoid bone.2 During the intervening years, other classification schemes have been put forth, generally for more invasive surgical.3,4 In view of the success obtained with laser treatment for neck rejuvenation, the authors have recently taken an algorithmic approach to developing a 7-category classification system of the aging conditions throughout the anatomic spectrum of three areas: skin, fat, and muscle published in conjunction with treatment approaches. The categories start at 1 = skin (normal), fat (any excess), muscle (normal) to 7 = skin (laxity in neck, cheek, and jowls), fat (normal or any excess), muscle (moderate to full platysmal bands). Appropriate treatments including the use of laser, ultrasonic technology, and toxins are recommended for each category.1 Treatments include the utilization of laser, ultrasonic technology, radiofrequency, and toxins, and options correlated with the presence and severity of conditions (Table 1). Table 1. Classification of Neck and Treatment Options Category Tissue component Treatment Skin (laxity) Fat (amount) Muscle (banding) 1440-nm laser Suction Surgery 1 Normal Any excess Normal ✓ Conditionalb None 2 Mild-moderate Normal Normal ✓ None None 3 Mild-moderate Mild to excessive Normal ✓ Conditionalc None 4 Mild-moderate Moderate to severe Normal ✓ ✓d None 5 Normal, mild, or moderate Normal or any fat excess Slight upper banding ✓ ✓ Nonee 6 Neck only Normal or any fat excess Moderate to full platysmal bands ✓a ✓ Yes (neck only) 7 Neck, cheek, and jowls Normal or any fat excess Moderate to full platysmal bands ✓a ✓ Yes (full rhytidectomy) Category Tissue component Treatment Skin (laxity) Fat (amount) Muscle (banding) 1440-nm laser Suction Surgery 1 Normal Any excess Normal ✓ Conditionalb None 2 Mild-moderate Normal Normal ✓ None None 3 Mild-moderate Mild to excessive Normal ✓ Conditionalc None 4 Mild-moderate Moderate to severe Normal ✓ ✓d None 5 Normal, mild, or moderate Normal or any fat excess Slight upper banding ✓ ✓ Nonee 6 Neck only Normal or any fat excess Moderate to full platysmal bands ✓a ✓ Yes (neck only) 7 Neck, cheek, and jowls Normal or any fat excess Moderate to full platysmal bands ✓a ✓ Yes (full rhytidectomy) aOptional – done for contouring or undermining flap. bIf moderate to severe fat layer. cone or manual manipulation. dSuction is recommended in Category 5, 6, and 7 if fat is present. eMay consider toxin, microfocused ultrasound, or radiofrequency treatment. View Large Table 1. Classification of Neck and Treatment Options Category Tissue component Treatment Skin (laxity) Fat (amount) Muscle (banding) 1440-nm laser Suction Surgery 1 Normal Any excess Normal ✓ Conditionalb None 2 Mild-moderate Normal Normal ✓ None None 3 Mild-moderate Mild to excessive Normal ✓ Conditionalc None 4 Mild-moderate Moderate to severe Normal ✓ ✓d None 5 Normal, mild, or moderate Normal or any fat excess Slight upper banding ✓ ✓ Nonee 6 Neck only Normal or any fat excess Moderate to full platysmal bands ✓a ✓ Yes (neck only) 7 Neck, cheek, and jowls Normal or any fat excess Moderate to full platysmal bands ✓a ✓ Yes (full rhytidectomy) Category Tissue component Treatment Skin (laxity) Fat (amount) Muscle (banding) 1440-nm laser Suction Surgery 1 Normal Any excess Normal ✓ Conditionalb None 2 Mild-moderate Normal Normal ✓ None None 3 Mild-moderate Mild to excessive Normal ✓ Conditionalc None 4 Mild-moderate Moderate to severe Normal ✓ ✓d None 5 Normal, mild, or moderate Normal or any fat excess Slight upper banding ✓ ✓ Nonee 6 Neck only Normal or any fat excess Moderate to full platysmal bands ✓a ✓ Yes (neck only) 7 Neck, cheek, and jowls Normal or any fat excess Moderate to full platysmal bands ✓a ✓ Yes (full rhytidectomy) aOptional – done for contouring or undermining flap. bIf moderate to severe fat layer. cone or manual manipulation. dSuction is recommended in Category 5, 6, and 7 if fat is present. eMay consider toxin, microfocused ultrasound, or radiofrequency treatment. View Large The objective of the study is to confirm the 7-category classification system and treatment approaches based on clinical outcome data for treatment of the mandibular and submandibular areas, specifically for skin tightening and laser lipolysis after a single 1440-nm laser treatment. The study uses the PrecisionTx™ platform with 1440-nm laser with the SideLaze800™ side-firing fiber (Cynosure, Westford, MA) (Figure 1). This approach suggests design and subsequent validation of an algorithm for treatment of neck rejuvenation. Figure 1. View largeDownload slide Hand piece of PrecisionTX (A) compared to SmirtLipo (B). The PrecisionTX hand piece is designed to treat smaller areas, such as the face and neck. Figure 1. View largeDownload slide Hand piece of PrecisionTX (A) compared to SmirtLipo (B). The PrecisionTX hand piece is designed to treat smaller areas, such as the face and neck. METHODS Patients Patients were recruited from the author’s private plastic surgery clinic. The study enrolled patients who came to the clinic at various times after having had neck rejuvenation treatment. The study was approved by an independent Institutional Review Board (Plantation, FL), and all patients provided signed informed consent.1 Eligible subjects included healthy adults, male or female with unwanted skin laxity and fat in the mandibular and submandibular areas willing to undergo a single laser treatment at 1440-nm using the PrecisionTx™ platform with 1440-nm wavelength. The Precision TX™ has the proprietary Sidelaze®800 side-firing fiber to deliver the 1440-nm wavelength. Subjects had to understand and accept the obligation to be present for all scheduled follow-up visits, can provide written consent to participate in the study and any other practice consents for anesthesia and surgical procedures, and to have facial photographs taken. Patients were excluded from participation in the trial if any of the following were present: any procedure in the midface to submandibular areas in the last six months; history of thrombophlebitis, history of coagulation disorders or anticoagulant medications; significant systemic illness or immunity disorder or localized condition affecting treatment area; had a history of keloid formation, had allergic reactions to local anesthesia, susceptible to light-induced seizures or history of seizures or medications which produce a photosensitizing effect; pregnant, breast feeding or planning a pregnancy or had a BMI above 30. Also excluded were those that had any other medical condition, that in the investigator’s opinion would interfere with the subject’s participation in the study Methods The study took place from March 2010 to January 2012 and used the PrecisionTX™ 1440-nm wavelength laser with side-firing fiber for minimally invasive procedure for neck rejuvenation. PrecisionTx™ (formerly known as SideLaze®800) is the latest technology in laser facial and neck contouring. The laser delivery system had Smartlipo Triplex, equipped with a fiber having side-firing capabilities (SideLaze®800) enclosed in a thermal-sensing cannula (ThermaGuide™), has been optimized for treatment of smaller areas such as lower half of face and neck. PrecisionTx™ has a new, smaller hand piece, a shorter cannula than the Smartlipo hand piece and is specifically designed for smaller treatment areas and precise energy delivery (Figure 1). The treatment wavelength of 1440-nm is highly absorbed in adipose tissue and by water, which is 70% of the dermis and is the most efficacious wavelength in melting of fat layers and tightening of subcutaneous tissue.5–9 Treatment Patients were categorized based on conditions utilizing previous published treatment classifications and treatment guidelines.1 Each patient was marked with 5x5 cm squares and given a single treatment with the 1440nm wavelength and a side-firing fiber with an average of 4914 total joules at 8 watts with average tumescence of 163ccs. The treatment area was marked into 5x5 cm squares, cleansed with a povidone-iodine solution, and three 3–5 mm incisions were placed in the central submental area and in the lower post-auricular such that the trajectory was in line with the submandibular plane. Patients with extended laxity, might have required treatment of skin only to the level just above the clavicle with two additional incisions. Tumescent anesthesia was infiltrated through the incision at 20–40 cc per 5x5 cm square using the Hunstad formula method.10 Temperature was set at 45°C on the ThermaGuide cannula (Cynosure, Inc.), and power setting was 6–8 watts at 25 Hz. The fat layer was treated first with 500–800J per marked square or 41°C, the skin layer was treated with 47C with the ThermaGuide temperature monitor in place. The 300–400J is recommended for the skin layer. Suction may be done if necessary, based on the amount of fat to be removed. The incisions were then sutured, a compression garment applied and the patient was instructed to wear it for 1-week post-procedure. Patients were placed on oral antibiotic for 1 week.1 Patients underwent a single laser treatment to the neck at 1440 nm wavelength (Precision TX™, Cynosure, Inc.) under local tumescence anesthesia as previously described.1 Energy was emitted through an 800μm side-firing fiber (SideLaze®800). One day before treatment, patients were weighed, given oral antibiotics, and high-resolution photographs were taken. Controlled laser energy was then applied along undersurface of lower half of face and the neck. Subjects presented for follow-up at 1-week, 3-months, and 6-months post-treatment. High-resolution photographs were obtained for independent evaluation and both physician and patient satisfaction scores were recorded. Evaluations Photographs for the Cervicomental Angle Scale (CAS) baseline evaluation were from patient photographs taken at the patient’s initial treatment visit at the author’s clinic. For this study follow-up photographs were taken at each follow-up visit. The CAS is a 4-point scale where Grade 1=a normal angle; Grade 2=mild; Grade 3=moderate; and Grade 4=severely oblique (Figure 2). Therefore, a 3-score improvement is the best score possible. Figure 2. View largeDownload slide Cervicomental Angle Scale (CAS). Representative Grade I (female), Grade II (female), Grade III (female), and Grade IV (male) patients (ages unknown) are shown. Figure 2. View largeDownload slide Cervicomental Angle Scale (CAS). Representative Grade I (female), Grade II (female), Grade III (female), and Grade IV (male) patients (ages unknown) are shown. Compared to baseline photographs, live assessments by the Global Aesthetic Improvement Scale (GAIS), a 5-point scale ranging from “worse” to “very much improved” (Table 2), was conducted by the treating Investigator at the 3 months follow-up visit. CAS is a categorization of progressive neck angle changes, laxity, and tosis and GAIS is a generalized aesthetic qualitative assessment by the observer. Table 2. Global Aesthetic Improvement Scale Assessment (GAIS) Rating Description 1 Very much improved Optimal cosmetic result in this subject 2 Much improved Marked improvement in appearance form the initial condition, but not completely optimal for this subject 3 Improved Obvious improvement in appearance from initial condition, but a re-treatment is indicated 4 No change The appearance is essentially the same as the original condition 5 Worse The appearance is worse than the original condition Rating Description 1 Very much improved Optimal cosmetic result in this subject 2 Much improved Marked improvement in appearance form the initial condition, but not completely optimal for this subject 3 Improved Obvious improvement in appearance from initial condition, but a re-treatment is indicated 4 No change The appearance is essentially the same as the original condition 5 Worse The appearance is worse than the original condition View Large Table 2. Global Aesthetic Improvement Scale Assessment (GAIS) Rating Description 1 Very much improved Optimal cosmetic result in this subject 2 Much improved Marked improvement in appearance form the initial condition, but not completely optimal for this subject 3 Improved Obvious improvement in appearance from initial condition, but a re-treatment is indicated 4 No change The appearance is essentially the same as the original condition 5 Worse The appearance is worse than the original condition Rating Description 1 Very much improved Optimal cosmetic result in this subject 2 Much improved Marked improvement in appearance form the initial condition, but not completely optimal for this subject 3 Improved Obvious improvement in appearance from initial condition, but a re-treatment is indicated 4 No change The appearance is essentially the same as the original condition 5 Worse The appearance is worse than the original condition View Large Safety Safety was assessed through the recording of all adverse events (AE), including physician and patient observations throughout the course of the study. Subjects completed a patient satisfaction questionnaire at the three and six months follow-up visits. RESULTS The study enrolled 25 patients (4 males; 21 females). The age range was 33–67 years (average, 47.9 years). The BMI range was 23–35.4 kg/m2 (average, 26.9 kg/m2). Patients were treated for mild to moderate adiposity and mild to moderate skin laxity in the neck. Of the 25 patients enrolled in the study, 21 were evaluated. Of the four patients not evaluable, two were missing data and two were lost to follow-up. Three evaluators graded blinded baseline and posttreatment photographs. The mean of 3 CAS scores was calculated and the mean change from baseline, and the improvement score, was determined Table 3). Subjects were rated grades II-III (2.9 ± 0.8) on average at baseline and grades I-II (1.3 ± 0.5) at follow-up. The average improvement was a mean score of 1.5 ± 0.7. Most patients, 23/25 (92%), showed at least a 1 score improvement. Reviewers were also asked to rate global aesthetic improvement (GAIS). Most of the subjects received a rating of 1 (very much improved- optimal cosmetic result for this subject). One person received a score of 4, where no change was seen (this subject also received a score of 1 on CAS, indicating that they were not an ideal candidate for this treatment). One subject received a GAIS score of 3, indicating that retreatment could be needed. Table 3. Improvement Based on Cervicomental Angle Scale (CAS) and Global Aesthetic Improvement Score (GAIS) CAS GAIS Baseline —  Mean ± SD 2.9 ± 0.8  Range 1.0–2.0 Follow-up —  Mean ± SD 1.3 ± 0.5  Range 1.0–2.0 Change in mean score Follow-up  Mean ± SD 1.5 ± 0.7 1.5 ± 0.9  Range 0.0–3.0 1.0–4.0 CAS GAIS Baseline —  Mean ± SD 2.9 ± 0.8  Range 1.0–2.0 Follow-up —  Mean ± SD 1.3 ± 0.5  Range 1.0–2.0 Change in mean score Follow-up  Mean ± SD 1.5 ± 0.7 1.5 ± 0.9  Range 0.0–3.0 1.0–4.0 SD, standard deviation. *Statistical analysis beyond standard deviation and range was not performed. View Large Table 3. Improvement Based on Cervicomental Angle Scale (CAS) and Global Aesthetic Improvement Score (GAIS) CAS GAIS Baseline —  Mean ± SD 2.9 ± 0.8  Range 1.0–2.0 Follow-up —  Mean ± SD 1.3 ± 0.5  Range 1.0–2.0 Change in mean score Follow-up  Mean ± SD 1.5 ± 0.7 1.5 ± 0.9  Range 0.0–3.0 1.0–4.0 CAS GAIS Baseline —  Mean ± SD 2.9 ± 0.8  Range 1.0–2.0 Follow-up —  Mean ± SD 1.3 ± 0.5  Range 1.0–2.0 Change in mean score Follow-up  Mean ± SD 1.5 ± 0.7 1.5 ± 0.9  Range 0.0–3.0 1.0–4.0 SD, standard deviation. *Statistical analysis beyond standard deviation and range was not performed. View Large Figures 3-7 illustrate typical results. Common posttreatment side effects included: temporary swelling, redness, bruising, soreness, and numbness in and around the treated areas. Side effects were transient in nature and subsided within 1–2 weeks posttreatment. No serious adverse events were reported. Figure 3. View largeDownload slide (A) Baseline and (B) 1-week posttreatment photographs of this 67-year-old woman with a BMI of 28.3 kg/m2 (160 lbs, 5’3”). Average CAS at baseline was 3.0 and at 1-week follow-up was 1.3. She had a mean improvement of 1.7. Figure 3. View largeDownload slide (A) Baseline and (B) 1-week posttreatment photographs of this 67-year-old woman with a BMI of 28.3 kg/m2 (160 lbs, 5’3”). Average CAS at baseline was 3.0 and at 1-week follow-up was 1.3. She had a mean improvement of 1.7. Figure 4. View largeDownload slide (A) Baseline and (B) 10-week post-treatment photographs of this 33-year-old woman with a BMI of 27.5 kg/m2 (160 lbs, 5’4”). Average CAS at baseline was 2.0 and at 1-week follow-up was 1.0. She had a mean improvement of 1.0. Figure 4. View largeDownload slide (A) Baseline and (B) 10-week post-treatment photographs of this 33-year-old woman with a BMI of 27.5 kg/m2 (160 lbs, 5’4”). Average CAS at baseline was 2.0 and at 1-week follow-up was 1.0. She had a mean improvement of 1.0. Figure 5. View largeDownload slide (A) Baseline and (B) 4-week post-treatment photographs of this 42-year-old woman with a BMI of 23 kg/m2 (138 lbs, 5’5”). Average CAS at baseline was 2.0 and at 1-week follow-up was 1.0. She had a mean improvement of 1.0. Figure 5. View largeDownload slide (A) Baseline and (B) 4-week post-treatment photographs of this 42-year-old woman with a BMI of 23 kg/m2 (138 lbs, 5’5”). Average CAS at baseline was 2.0 and at 1-week follow-up was 1.0. She had a mean improvement of 1.0. Figure 6. View largeDownload slide (A) Baseline and (B) 2-month post-treatment photographs of this 44-year-old man with a BMI of 35.4 kg/m2 (200 lbs, 5’3”). Average CAS at baseline was 4.0 and at 1-week follow-up was 2.0. He had a mean improvement of 2.0. Figure 6. View largeDownload slide (A) Baseline and (B) 2-month post-treatment photographs of this 44-year-old man with a BMI of 35.4 kg/m2 (200 lbs, 5’3”). Average CAS at baseline was 4.0 and at 1-week follow-up was 2.0. He had a mean improvement of 2.0. Figure 7. View largeDownload slide (A) Baseline and (B) 2-year post-treatment photographs of this 53-year-old woman with a BMI of 24.5 kg/m2 (143 lbs, 5’4”). Average CAS at baseline was 3.7 and at 1-week follow-up was 1.0. She had a mean improvement of 2.7. Figure 7. View largeDownload slide (A) Baseline and (B) 2-year post-treatment photographs of this 53-year-old woman with a BMI of 24.5 kg/m2 (143 lbs, 5’4”). Average CAS at baseline was 3.7 and at 1-week follow-up was 1.0. She had a mean improvement of 2.7. DISCUSSION Traditionally rejuvenation of the lower face has been accomplished by surgical options for each anatomic layer affected, namely, skin, fat, and muscle. The emergence of recent laser technology has proven to offer a modality that can provide additional benefits when treating the first two anatomical layers of the neck; skin laxity and excessive fat. The proposed 7-category classification and treatment is a practical guideline for diagnosis and optimal treatment of patients for neck rejuvenation. The classification is intended to serve as a guide to determine appropriate and effective treatment options for aging muscle, fat, and skin. The scale is intended to aid the clinician in categorizing patients based on aging anatomic layers, which will correlate with specific treatment options. These recommendations evaluate and distill a decade long proliferation of technologies and devices. We confirm that the laser has dramatically changed the treatment of neck rejuvenation to be less invasive with faster recovery than previous surgical methods. Moreover, laser treatment is appropriate in all 7 categories alone or in cases involving platysmal bands, in addition to other modalities. Laser treatment for skin rejuvenation has a long history. Recent studies have shown improvements in recovery time, higher patient satisfaction rates, and improvements in skin tightening through tissue coagulation. Laser assisted neck lifts are recommended for those patients with moderate to full amounts of supraplatysmal fat and good skin tone.11 Laser treatment is also appropriate for improvement to the lower face, which included the submentum, jowls, neck skin, jaw line, cervicomental angle, oral commissures, and nasolabial grooves.12 It is a less invasive approach than surgery to dissect in the plane between skin and subcutaneous fat and the platysma and is an adjunct to advanced surgical facial rejuvenation procedure such as rhytidectomy.13 Delivery of thermally controlled laser assisted energy subcutaneously leads to reorganization of the reticular dermis and generation of new collagen resulting in skin shrinkage and increased skin elasticity. Early reports showed a major benefit when treating skin laxity as stand-alone treatment or as a beneficial compliment to fat removal.14,15 Later reports have also documented the skin shrinkage and improvement in elasticity, demonstrating the regeneration of collagen remodeling5,16 and production of new collagen.8,17 The mechanism of this phenomenon is gradually being elucidated.18 Muscle is the third component, and to combat its changes toxins, mainly botulinum toxin A, is employed for neck rejuvenation. De-nerving the muscle will lessen some of the exerted tension and reduce wrinkling and pronouncement of the banding caused by the pulling of the platysmal muscle as a major contributor to the aging mechanism of the cervical region by pulling the skin and lower facial structures.19–21 Selective transcutaneous delivery of ultrasound energy can be directed at various depths to produce coagulative necrosis in visceral soft tissue and can be focused on well-defined thermal zones, including the muscle layer.22 Although significant improvement is observed through energy devices and minimally invasive treatments, patients with a high degree of laxity and loss of elasticity are not ideal candidates. Also, patients over 70 years old are not ideal candidates. A limitation is that is we only had one energy source for neck improvement. There are other sources as well beyond the scope of this study. However, they can be evaluated in future work. Noninvasive methods include cryolipolysis, lasers, and other minimally invasive radiofrequency options. CONCLUSION This study confirms a new minimally invasive treatment approach based on a unique classification system with no adverse events reported and high patient satisfaction. The 7-category classification system is designed to match each patient’s neck condition with the most appropriate rejuvenation treatment plan. We hope that practitioners will see the value of the classification system, the benefit of 1440-nm treatment, and report their experiences. Disclosures Dr DiBernardo is a paid research and training consultant to Cynosure, Inc. (Westford, MA). Ms DiBernardo declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding This article was supported by Cynosure, Inc. (Westford, MA), who co-funded the development of this supplement. Acknowledgments This work was supported by Cynosure, Inc., including equipment, writing, and procedure costs. REFERENCES 1. Dibernardo BE . The aging neck: a diagnostic approach to surgical and nonsurgical options . J Cosmet Laser Ther . 2013 ; 15 ( 2 ): 56 - 64 . Google Scholar CrossRef Search ADS PubMed 2. Dedo DD . “How I do it”–plastic surgery. Practical suggestions on facial plastic surgery. A preoperative classification of the neck for cervicofacial rhytidectomy . Laryngoscope . 1980 ; 90 ( 11 ): 1894 - 1896 . Google Scholar CrossRef Search ADS PubMed 3. Rohrich RJ , Rios JL , Smith PD , Gutowski KA . Neck rejuvenation revisited . Plast Reconstr Surg . 2006 ; 118 ( 5 ): 1251 - 1263 . Google Scholar CrossRef Search ADS PubMed 4. McCollough EG . The McCollough facial rejuvenation system: a condition-specific classification algorithm . Facial Plast Surg . 2011 ; 27 ( 1 ): 112 - 123 . Google Scholar CrossRef Search ADS PubMed 5. DiBernardo BE . Randomized, blinded split abdomen study evaluating skin shrinkage and skin tightening in laser-assisted liposuction versus liposuction control . Aesthet Surg J . 2010 ; 30 ( 4 ): 593 - 602 . Google Scholar CrossRef Search ADS PubMed 6. DiBernardo BE . Treatment of cellulite using a 1440-nm pulsed laser with one-year follow-up . Aesthet Surg J . 2011 ; 31 ( 3 ): 328 - 341 . Google Scholar CrossRef Search ADS PubMed 7. Duck FA. Physical Properties of Tissue . London : Academic Press ; 1990 : 320 - 328 . 8. Sarnoff DS . Evaluation of the safety and efficacy of a novel 1440nm Nd:YAG laser for neck contouring and skin tightening without liposuction . J Drugs Dermatol . 2013 ; 12 ( 12 ): 1382 - 1388 . Google Scholar PubMed 9. Sasaki GH . Early clinical experience with the 1440-nm wavelength internal pulsed laser in facial rejuvenation: two-year follow-up . Clin Plast Surg . 2012 ; 39 ( 4 ): 409 - 417 . Google Scholar CrossRef Search ADS PubMed 10. Hunstad JP . Tumescent and syringe liposculpture: a logical partnership . Aesthetic Plast Surg . 1995 ; 19 ( 4 ): 321 - 333 . Google Scholar CrossRef Search ADS PubMed 11. Caplin DA , Perlyn CA . Rejuvenation of the aging neck: current principles, techniques, and newer modifications . Facial Plast Surg Clin North Am . 2009 ; 17 ( 4 ): 589 - 601 , vi. Google Scholar CrossRef Search ADS PubMed 12. McMenamin P . Laser face-lifts: a new paradigm in face-lift surgery . Facial Plast Surg . 2011 ; 27 ( 4 ): 299 - 307 . Google Scholar CrossRef Search ADS PubMed 13. Gentile RD . Laser-assisted neck-lift: high-tech contouring and tightening . Facial Plast Surg . 2011 ; 27 ( 4 ): 331 - 345 . Google Scholar CrossRef Search ADS PubMed 14. Badin AZ , Moraes LM , Gondek L , Chiaratti MG , Canta L . Laser lipolysis: flaccidity under control . Aesthetic Plast Surg . 2002 ; 26 ( 5 ): 335 - 339 . Google Scholar CrossRef Search ADS PubMed 15. Goldman A . Submental Nd:YAG laser-assisted liposuction . Lasers Surg Med . 2006 ; 38 ( 3 ): 181 - 184 . Google Scholar CrossRef Search ADS PubMed 16. DiBernardo BE , Reyes J . Evaluation of skin tightening after laser-assisted liposuction . Aesthet Surg J . 2009 ; 29 ( 5 ): 400 - 407 . Google Scholar CrossRef Search ADS PubMed 17. McBean JC , Katz BE . A pilot study of the efficacy of a 1,064 and 1,320 nm sequentially firing Nd:YAG laser device for lipolysis and skin tightening . Lasers Surg Med . 2009 ; 41 ( 10 ): 779 - 784 . Google Scholar CrossRef Search ADS PubMed 18. Orringer JS , Rittié L , Baker D , Voorhees JJ , Fisher G . Molecular mechanisms of nonablative fractionated laser resurfacing . Br J Dermatol . 2010 ; 163 ( 4 ): 757 - 768 . Google Scholar CrossRef Search ADS PubMed 19. Brandt FS , Boker A . Botulinum toxin for rejuvenation of the neck . Clin Dermatol . 2003 ; 21 ( 6 ): 513 - 520 . Google Scholar CrossRef Search ADS PubMed 20. Matarasso A , Matarasso SL , Brandt FS , Bellman B . Botulinum A exotoxin for the management of platysma bands . Plast Reconstr Surg . 1999 ; 103 ( 2 ): 645 - 652 ; discussion 653. Google Scholar CrossRef Search ADS PubMed 21. Kane MA . Nonsurgical treatment of platysma bands with injection of botulinum toxin a revisited . Plast Reconstr Surg . 2003 ; 112 ( 5 ): 125S - 126S . Google Scholar CrossRef Search ADS PubMed 22. White WM , Makin IR , Slayton MH , Barthe PG , Gliklich R . Selective transcutaneous delivery of energy to porcine soft tissues using Intense Ultrasound (IUS) . Lasers Surg Med . 2008 ; 40 ( 2 ): 67 - 75 . Google Scholar CrossRef Search ADS PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

Prediction of Treatment Outcomes for Neck Rejuvenation Utilizing a Unique Classification System of Treatment Approach Using a 1440-nm Side-Firing Laser

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Abstract

Abstract Background The appearance of a youthful neck is lost with age causing excessive skin laxity, a loss of subcutaneous fat, prominence of platysmal banding, and jowling. In view of the success obtained with laser treatment for neck rejuvenation, the authors have recently taken an algorithmic approach to developing a 7-category classification system of the aging conditions throughout the anatomic spectrum of three areas: skin, fat, and muscle. This system will correlate with specific treatment options. Objective The objective of the study was to confirm the 7-category classification system and treatment approaches based on clinical outcome data for treatment of the mandibular and submandibular areas, specifically for skin tightening and laser lipolysis after a single 1440-nm laser treatment. Methods Patients were treated with a single treatment of PrecisionTX™ 1440-nm wavelength laser on their necks. Baseline and posttreatment photographs were taken and evaluated by 3 blinded reviewers using the Cervicomental Angle Scale (CAS). Results Subjects were rated grades II-III (2.9 ± 0.8) on average at baseline and grades I-II (1.3 ± 0.5) at follow-up. The average improvement was a mean score of 1.5 ± 0.07. Patients, 23/25 (92%), showed at least a 1 score improvement. Conclusions This study confirms a new minimally invasive treatment approach based on a unique classification system with no adverse events reported and high patient satisfaction. Level of Evidence: 4 The lower face represents one of the most prominent indicators of aging. A youthful neck appearance is defined by good skin tone, a well-defined cervicomental angle and mandibular border, without signs of platysmal banding and submental fat accumulation. With age, the skin will lose collagen and elastin causing excessive skin laxity, a loss of subcutaneous fat, prominence of platysmal banding, and jowling. Even in some youthful patients, fat accumulation occurs resulting in a lack of definition of the mandible and cervicomental angle.1 During the past 20 years, there has been a proliferation of technologies and devices for neck rejuvenation.1 Consequently, the question of how to treat the neck and what technique to employ when needed becomes important, with an ultimate aim of standardization. Review of our database of patients from our plastic surgery clinic revealed patterns of diagnosis and treatment. Our published report of the findings defines the characteristics of various patient types to develop a diagnostic approach to treatment options for neck rejuvenation. In this study the authors expand the classification and treatment scheme for neck rejuvenation, and recommend treatment approaches using the most recent advances. Intrinsic and extrinsic factors at progressive stages of life affect the neck and present as unwanted signs of aging. These effects are typically found in three anatomic layers, which include the skin, muscle, and fat layers. Loss of subcutaneous fat, prominence of platysmal banding, jowling along the mandibular border, and excessive skin laxity due to loss of collagen and elastin are common conditions that are treated. Enhancement of the aging neck has improved over the last 30 years with a trend toward less invasive procedures and smaller incisions. Lasers have traditionally improved skin surface, texture, and laxity in the face. Neck skin however, is more limited in its healing capacity from external insults. Previous to the development of a plethora of treatments for body sculpting and skin rejuvenation, a 6-category classification system was developed based on changes to the anatomical layers of the neck. The first class describes a youthful neck with a well-defined cervical mental angle, minimal submental fat, good skin and platysma tone. The second class represents laxity of the cervical skin without significant submental fat or platysmal banding. The third class contains a layer of subcutaneous fat, which is either genetic or acquired in need of removal. The fourth class describes platysmal banding and the fifth presents retrognathics. Lastly, class 6 are cases that contain a low hyoid bone.2 During the intervening years, other classification schemes have been put forth, generally for more invasive surgical.3,4 In view of the success obtained with laser treatment for neck rejuvenation, the authors have recently taken an algorithmic approach to developing a 7-category classification system of the aging conditions throughout the anatomic spectrum of three areas: skin, fat, and muscle published in conjunction with treatment approaches. The categories start at 1 = skin (normal), fat (any excess), muscle (normal) to 7 = skin (laxity in neck, cheek, and jowls), fat (normal or any excess), muscle (moderate to full platysmal bands). Appropriate treatments including the use of laser, ultrasonic technology, and toxins are recommended for each category.1 Treatments include the utilization of laser, ultrasonic technology, radiofrequency, and toxins, and options correlated with the presence and severity of conditions (Table 1). Table 1. Classification of Neck and Treatment Options Category Tissue component Treatment Skin (laxity) Fat (amount) Muscle (banding) 1440-nm laser Suction Surgery 1 Normal Any excess Normal ✓ Conditionalb None 2 Mild-moderate Normal Normal ✓ None None 3 Mild-moderate Mild to excessive Normal ✓ Conditionalc None 4 Mild-moderate Moderate to severe Normal ✓ ✓d None 5 Normal, mild, or moderate Normal or any fat excess Slight upper banding ✓ ✓ Nonee 6 Neck only Normal or any fat excess Moderate to full platysmal bands ✓a ✓ Yes (neck only) 7 Neck, cheek, and jowls Normal or any fat excess Moderate to full platysmal bands ✓a ✓ Yes (full rhytidectomy) Category Tissue component Treatment Skin (laxity) Fat (amount) Muscle (banding) 1440-nm laser Suction Surgery 1 Normal Any excess Normal ✓ Conditionalb None 2 Mild-moderate Normal Normal ✓ None None 3 Mild-moderate Mild to excessive Normal ✓ Conditionalc None 4 Mild-moderate Moderate to severe Normal ✓ ✓d None 5 Normal, mild, or moderate Normal or any fat excess Slight upper banding ✓ ✓ Nonee 6 Neck only Normal or any fat excess Moderate to full platysmal bands ✓a ✓ Yes (neck only) 7 Neck, cheek, and jowls Normal or any fat excess Moderate to full platysmal bands ✓a ✓ Yes (full rhytidectomy) aOptional – done for contouring or undermining flap. bIf moderate to severe fat layer. cone or manual manipulation. dSuction is recommended in Category 5, 6, and 7 if fat is present. eMay consider toxin, microfocused ultrasound, or radiofrequency treatment. View Large Table 1. Classification of Neck and Treatment Options Category Tissue component Treatment Skin (laxity) Fat (amount) Muscle (banding) 1440-nm laser Suction Surgery 1 Normal Any excess Normal ✓ Conditionalb None 2 Mild-moderate Normal Normal ✓ None None 3 Mild-moderate Mild to excessive Normal ✓ Conditionalc None 4 Mild-moderate Moderate to severe Normal ✓ ✓d None 5 Normal, mild, or moderate Normal or any fat excess Slight upper banding ✓ ✓ Nonee 6 Neck only Normal or any fat excess Moderate to full platysmal bands ✓a ✓ Yes (neck only) 7 Neck, cheek, and jowls Normal or any fat excess Moderate to full platysmal bands ✓a ✓ Yes (full rhytidectomy) Category Tissue component Treatment Skin (laxity) Fat (amount) Muscle (banding) 1440-nm laser Suction Surgery 1 Normal Any excess Normal ✓ Conditionalb None 2 Mild-moderate Normal Normal ✓ None None 3 Mild-moderate Mild to excessive Normal ✓ Conditionalc None 4 Mild-moderate Moderate to severe Normal ✓ ✓d None 5 Normal, mild, or moderate Normal or any fat excess Slight upper banding ✓ ✓ Nonee 6 Neck only Normal or any fat excess Moderate to full platysmal bands ✓a ✓ Yes (neck only) 7 Neck, cheek, and jowls Normal or any fat excess Moderate to full platysmal bands ✓a ✓ Yes (full rhytidectomy) aOptional – done for contouring or undermining flap. bIf moderate to severe fat layer. cone or manual manipulation. dSuction is recommended in Category 5, 6, and 7 if fat is present. eMay consider toxin, microfocused ultrasound, or radiofrequency treatment. View Large The objective of the study is to confirm the 7-category classification system and treatment approaches based on clinical outcome data for treatment of the mandibular and submandibular areas, specifically for skin tightening and laser lipolysis after a single 1440-nm laser treatment. The study uses the PrecisionTx™ platform with 1440-nm laser with the SideLaze800™ side-firing fiber (Cynosure, Westford, MA) (Figure 1). This approach suggests design and subsequent validation of an algorithm for treatment of neck rejuvenation. Figure 1. View largeDownload slide Hand piece of PrecisionTX (A) compared to SmirtLipo (B). The PrecisionTX hand piece is designed to treat smaller areas, such as the face and neck. Figure 1. View largeDownload slide Hand piece of PrecisionTX (A) compared to SmirtLipo (B). The PrecisionTX hand piece is designed to treat smaller areas, such as the face and neck. METHODS Patients Patients were recruited from the author’s private plastic surgery clinic. The study enrolled patients who came to the clinic at various times after having had neck rejuvenation treatment. The study was approved by an independent Institutional Review Board (Plantation, FL), and all patients provided signed informed consent.1 Eligible subjects included healthy adults, male or female with unwanted skin laxity and fat in the mandibular and submandibular areas willing to undergo a single laser treatment at 1440-nm using the PrecisionTx™ platform with 1440-nm wavelength. The Precision TX™ has the proprietary Sidelaze®800 side-firing fiber to deliver the 1440-nm wavelength. Subjects had to understand and accept the obligation to be present for all scheduled follow-up visits, can provide written consent to participate in the study and any other practice consents for anesthesia and surgical procedures, and to have facial photographs taken. Patients were excluded from participation in the trial if any of the following were present: any procedure in the midface to submandibular areas in the last six months; history of thrombophlebitis, history of coagulation disorders or anticoagulant medications; significant systemic illness or immunity disorder or localized condition affecting treatment area; had a history of keloid formation, had allergic reactions to local anesthesia, susceptible to light-induced seizures or history of seizures or medications which produce a photosensitizing effect; pregnant, breast feeding or planning a pregnancy or had a BMI above 30. Also excluded were those that had any other medical condition, that in the investigator’s opinion would interfere with the subject’s participation in the study Methods The study took place from March 2010 to January 2012 and used the PrecisionTX™ 1440-nm wavelength laser with side-firing fiber for minimally invasive procedure for neck rejuvenation. PrecisionTx™ (formerly known as SideLaze®800) is the latest technology in laser facial and neck contouring. The laser delivery system had Smartlipo Triplex, equipped with a fiber having side-firing capabilities (SideLaze®800) enclosed in a thermal-sensing cannula (ThermaGuide™), has been optimized for treatment of smaller areas such as lower half of face and neck. PrecisionTx™ has a new, smaller hand piece, a shorter cannula than the Smartlipo hand piece and is specifically designed for smaller treatment areas and precise energy delivery (Figure 1). The treatment wavelength of 1440-nm is highly absorbed in adipose tissue and by water, which is 70% of the dermis and is the most efficacious wavelength in melting of fat layers and tightening of subcutaneous tissue.5–9 Treatment Patients were categorized based on conditions utilizing previous published treatment classifications and treatment guidelines.1 Each patient was marked with 5x5 cm squares and given a single treatment with the 1440nm wavelength and a side-firing fiber with an average of 4914 total joules at 8 watts with average tumescence of 163ccs. The treatment area was marked into 5x5 cm squares, cleansed with a povidone-iodine solution, and three 3–5 mm incisions were placed in the central submental area and in the lower post-auricular such that the trajectory was in line with the submandibular plane. Patients with extended laxity, might have required treatment of skin only to the level just above the clavicle with two additional incisions. Tumescent anesthesia was infiltrated through the incision at 20–40 cc per 5x5 cm square using the Hunstad formula method.10 Temperature was set at 45°C on the ThermaGuide cannula (Cynosure, Inc.), and power setting was 6–8 watts at 25 Hz. The fat layer was treated first with 500–800J per marked square or 41°C, the skin layer was treated with 47C with the ThermaGuide temperature monitor in place. The 300–400J is recommended for the skin layer. Suction may be done if necessary, based on the amount of fat to be removed. The incisions were then sutured, a compression garment applied and the patient was instructed to wear it for 1-week post-procedure. Patients were placed on oral antibiotic for 1 week.1 Patients underwent a single laser treatment to the neck at 1440 nm wavelength (Precision TX™, Cynosure, Inc.) under local tumescence anesthesia as previously described.1 Energy was emitted through an 800μm side-firing fiber (SideLaze®800). One day before treatment, patients were weighed, given oral antibiotics, and high-resolution photographs were taken. Controlled laser energy was then applied along undersurface of lower half of face and the neck. Subjects presented for follow-up at 1-week, 3-months, and 6-months post-treatment. High-resolution photographs were obtained for independent evaluation and both physician and patient satisfaction scores were recorded. Evaluations Photographs for the Cervicomental Angle Scale (CAS) baseline evaluation were from patient photographs taken at the patient’s initial treatment visit at the author’s clinic. For this study follow-up photographs were taken at each follow-up visit. The CAS is a 4-point scale where Grade 1=a normal angle; Grade 2=mild; Grade 3=moderate; and Grade 4=severely oblique (Figure 2). Therefore, a 3-score improvement is the best score possible. Figure 2. View largeDownload slide Cervicomental Angle Scale (CAS). Representative Grade I (female), Grade II (female), Grade III (female), and Grade IV (male) patients (ages unknown) are shown. Figure 2. View largeDownload slide Cervicomental Angle Scale (CAS). Representative Grade I (female), Grade II (female), Grade III (female), and Grade IV (male) patients (ages unknown) are shown. Compared to baseline photographs, live assessments by the Global Aesthetic Improvement Scale (GAIS), a 5-point scale ranging from “worse” to “very much improved” (Table 2), was conducted by the treating Investigator at the 3 months follow-up visit. CAS is a categorization of progressive neck angle changes, laxity, and tosis and GAIS is a generalized aesthetic qualitative assessment by the observer. Table 2. Global Aesthetic Improvement Scale Assessment (GAIS) Rating Description 1 Very much improved Optimal cosmetic result in this subject 2 Much improved Marked improvement in appearance form the initial condition, but not completely optimal for this subject 3 Improved Obvious improvement in appearance from initial condition, but a re-treatment is indicated 4 No change The appearance is essentially the same as the original condition 5 Worse The appearance is worse than the original condition Rating Description 1 Very much improved Optimal cosmetic result in this subject 2 Much improved Marked improvement in appearance form the initial condition, but not completely optimal for this subject 3 Improved Obvious improvement in appearance from initial condition, but a re-treatment is indicated 4 No change The appearance is essentially the same as the original condition 5 Worse The appearance is worse than the original condition View Large Table 2. Global Aesthetic Improvement Scale Assessment (GAIS) Rating Description 1 Very much improved Optimal cosmetic result in this subject 2 Much improved Marked improvement in appearance form the initial condition, but not completely optimal for this subject 3 Improved Obvious improvement in appearance from initial condition, but a re-treatment is indicated 4 No change The appearance is essentially the same as the original condition 5 Worse The appearance is worse than the original condition Rating Description 1 Very much improved Optimal cosmetic result in this subject 2 Much improved Marked improvement in appearance form the initial condition, but not completely optimal for this subject 3 Improved Obvious improvement in appearance from initial condition, but a re-treatment is indicated 4 No change The appearance is essentially the same as the original condition 5 Worse The appearance is worse than the original condition View Large Safety Safety was assessed through the recording of all adverse events (AE), including physician and patient observations throughout the course of the study. Subjects completed a patient satisfaction questionnaire at the three and six months follow-up visits. RESULTS The study enrolled 25 patients (4 males; 21 females). The age range was 33–67 years (average, 47.9 years). The BMI range was 23–35.4 kg/m2 (average, 26.9 kg/m2). Patients were treated for mild to moderate adiposity and mild to moderate skin laxity in the neck. Of the 25 patients enrolled in the study, 21 were evaluated. Of the four patients not evaluable, two were missing data and two were lost to follow-up. Three evaluators graded blinded baseline and posttreatment photographs. The mean of 3 CAS scores was calculated and the mean change from baseline, and the improvement score, was determined Table 3). Subjects were rated grades II-III (2.9 ± 0.8) on average at baseline and grades I-II (1.3 ± 0.5) at follow-up. The average improvement was a mean score of 1.5 ± 0.7. Most patients, 23/25 (92%), showed at least a 1 score improvement. Reviewers were also asked to rate global aesthetic improvement (GAIS). Most of the subjects received a rating of 1 (very much improved- optimal cosmetic result for this subject). One person received a score of 4, where no change was seen (this subject also received a score of 1 on CAS, indicating that they were not an ideal candidate for this treatment). One subject received a GAIS score of 3, indicating that retreatment could be needed. Table 3. Improvement Based on Cervicomental Angle Scale (CAS) and Global Aesthetic Improvement Score (GAIS) CAS GAIS Baseline —  Mean ± SD 2.9 ± 0.8  Range 1.0–2.0 Follow-up —  Mean ± SD 1.3 ± 0.5  Range 1.0–2.0 Change in mean score Follow-up  Mean ± SD 1.5 ± 0.7 1.5 ± 0.9  Range 0.0–3.0 1.0–4.0 CAS GAIS Baseline —  Mean ± SD 2.9 ± 0.8  Range 1.0–2.0 Follow-up —  Mean ± SD 1.3 ± 0.5  Range 1.0–2.0 Change in mean score Follow-up  Mean ± SD 1.5 ± 0.7 1.5 ± 0.9  Range 0.0–3.0 1.0–4.0 SD, standard deviation. *Statistical analysis beyond standard deviation and range was not performed. View Large Table 3. Improvement Based on Cervicomental Angle Scale (CAS) and Global Aesthetic Improvement Score (GAIS) CAS GAIS Baseline —  Mean ± SD 2.9 ± 0.8  Range 1.0–2.0 Follow-up —  Mean ± SD 1.3 ± 0.5  Range 1.0–2.0 Change in mean score Follow-up  Mean ± SD 1.5 ± 0.7 1.5 ± 0.9  Range 0.0–3.0 1.0–4.0 CAS GAIS Baseline —  Mean ± SD 2.9 ± 0.8  Range 1.0–2.0 Follow-up —  Mean ± SD 1.3 ± 0.5  Range 1.0–2.0 Change in mean score Follow-up  Mean ± SD 1.5 ± 0.7 1.5 ± 0.9  Range 0.0–3.0 1.0–4.0 SD, standard deviation. *Statistical analysis beyond standard deviation and range was not performed. View Large Figures 3-7 illustrate typical results. Common posttreatment side effects included: temporary swelling, redness, bruising, soreness, and numbness in and around the treated areas. Side effects were transient in nature and subsided within 1–2 weeks posttreatment. No serious adverse events were reported. Figure 3. View largeDownload slide (A) Baseline and (B) 1-week posttreatment photographs of this 67-year-old woman with a BMI of 28.3 kg/m2 (160 lbs, 5’3”). Average CAS at baseline was 3.0 and at 1-week follow-up was 1.3. She had a mean improvement of 1.7. Figure 3. View largeDownload slide (A) Baseline and (B) 1-week posttreatment photographs of this 67-year-old woman with a BMI of 28.3 kg/m2 (160 lbs, 5’3”). Average CAS at baseline was 3.0 and at 1-week follow-up was 1.3. She had a mean improvement of 1.7. Figure 4. View largeDownload slide (A) Baseline and (B) 10-week post-treatment photographs of this 33-year-old woman with a BMI of 27.5 kg/m2 (160 lbs, 5’4”). Average CAS at baseline was 2.0 and at 1-week follow-up was 1.0. She had a mean improvement of 1.0. Figure 4. View largeDownload slide (A) Baseline and (B) 10-week post-treatment photographs of this 33-year-old woman with a BMI of 27.5 kg/m2 (160 lbs, 5’4”). Average CAS at baseline was 2.0 and at 1-week follow-up was 1.0. She had a mean improvement of 1.0. Figure 5. View largeDownload slide (A) Baseline and (B) 4-week post-treatment photographs of this 42-year-old woman with a BMI of 23 kg/m2 (138 lbs, 5’5”). Average CAS at baseline was 2.0 and at 1-week follow-up was 1.0. She had a mean improvement of 1.0. Figure 5. View largeDownload slide (A) Baseline and (B) 4-week post-treatment photographs of this 42-year-old woman with a BMI of 23 kg/m2 (138 lbs, 5’5”). Average CAS at baseline was 2.0 and at 1-week follow-up was 1.0. She had a mean improvement of 1.0. Figure 6. View largeDownload slide (A) Baseline and (B) 2-month post-treatment photographs of this 44-year-old man with a BMI of 35.4 kg/m2 (200 lbs, 5’3”). Average CAS at baseline was 4.0 and at 1-week follow-up was 2.0. He had a mean improvement of 2.0. Figure 6. View largeDownload slide (A) Baseline and (B) 2-month post-treatment photographs of this 44-year-old man with a BMI of 35.4 kg/m2 (200 lbs, 5’3”). Average CAS at baseline was 4.0 and at 1-week follow-up was 2.0. He had a mean improvement of 2.0. Figure 7. View largeDownload slide (A) Baseline and (B) 2-year post-treatment photographs of this 53-year-old woman with a BMI of 24.5 kg/m2 (143 lbs, 5’4”). Average CAS at baseline was 3.7 and at 1-week follow-up was 1.0. She had a mean improvement of 2.7. Figure 7. View largeDownload slide (A) Baseline and (B) 2-year post-treatment photographs of this 53-year-old woman with a BMI of 24.5 kg/m2 (143 lbs, 5’4”). Average CAS at baseline was 3.7 and at 1-week follow-up was 1.0. She had a mean improvement of 2.7. DISCUSSION Traditionally rejuvenation of the lower face has been accomplished by surgical options for each anatomic layer affected, namely, skin, fat, and muscle. The emergence of recent laser technology has proven to offer a modality that can provide additional benefits when treating the first two anatomical layers of the neck; skin laxity and excessive fat. The proposed 7-category classification and treatment is a practical guideline for diagnosis and optimal treatment of patients for neck rejuvenation. The classification is intended to serve as a guide to determine appropriate and effective treatment options for aging muscle, fat, and skin. The scale is intended to aid the clinician in categorizing patients based on aging anatomic layers, which will correlate with specific treatment options. These recommendations evaluate and distill a decade long proliferation of technologies and devices. We confirm that the laser has dramatically changed the treatment of neck rejuvenation to be less invasive with faster recovery than previous surgical methods. Moreover, laser treatment is appropriate in all 7 categories alone or in cases involving platysmal bands, in addition to other modalities. Laser treatment for skin rejuvenation has a long history. Recent studies have shown improvements in recovery time, higher patient satisfaction rates, and improvements in skin tightening through tissue coagulation. Laser assisted neck lifts are recommended for those patients with moderate to full amounts of supraplatysmal fat and good skin tone.11 Laser treatment is also appropriate for improvement to the lower face, which included the submentum, jowls, neck skin, jaw line, cervicomental angle, oral commissures, and nasolabial grooves.12 It is a less invasive approach than surgery to dissect in the plane between skin and subcutaneous fat and the platysma and is an adjunct to advanced surgical facial rejuvenation procedure such as rhytidectomy.13 Delivery of thermally controlled laser assisted energy subcutaneously leads to reorganization of the reticular dermis and generation of new collagen resulting in skin shrinkage and increased skin elasticity. Early reports showed a major benefit when treating skin laxity as stand-alone treatment or as a beneficial compliment to fat removal.14,15 Later reports have also documented the skin shrinkage and improvement in elasticity, demonstrating the regeneration of collagen remodeling5,16 and production of new collagen.8,17 The mechanism of this phenomenon is gradually being elucidated.18 Muscle is the third component, and to combat its changes toxins, mainly botulinum toxin A, is employed for neck rejuvenation. De-nerving the muscle will lessen some of the exerted tension and reduce wrinkling and pronouncement of the banding caused by the pulling of the platysmal muscle as a major contributor to the aging mechanism of the cervical region by pulling the skin and lower facial structures.19–21 Selective transcutaneous delivery of ultrasound energy can be directed at various depths to produce coagulative necrosis in visceral soft tissue and can be focused on well-defined thermal zones, including the muscle layer.22 Although significant improvement is observed through energy devices and minimally invasive treatments, patients with a high degree of laxity and loss of elasticity are not ideal candidates. Also, patients over 70 years old are not ideal candidates. A limitation is that is we only had one energy source for neck improvement. There are other sources as well beyond the scope of this study. However, they can be evaluated in future work. Noninvasive methods include cryolipolysis, lasers, and other minimally invasive radiofrequency options. CONCLUSION This study confirms a new minimally invasive treatment approach based on a unique classification system with no adverse events reported and high patient satisfaction. The 7-category classification system is designed to match each patient’s neck condition with the most appropriate rejuvenation treatment plan. We hope that practitioners will see the value of the classification system, the benefit of 1440-nm treatment, and report their experiences. Disclosures Dr DiBernardo is a paid research and training consultant to Cynosure, Inc. (Westford, MA). Ms DiBernardo declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding This article was supported by Cynosure, Inc. (Westford, MA), who co-funded the development of this supplement. Acknowledgments This work was supported by Cynosure, Inc., including equipment, writing, and procedure costs. REFERENCES 1. Dibernardo BE . The aging neck: a diagnostic approach to surgical and nonsurgical options . J Cosmet Laser Ther . 2013 ; 15 ( 2 ): 56 - 64 . Google Scholar CrossRef Search ADS PubMed 2. Dedo DD . “How I do it”–plastic surgery. Practical suggestions on facial plastic surgery. A preoperative classification of the neck for cervicofacial rhytidectomy . Laryngoscope . 1980 ; 90 ( 11 ): 1894 - 1896 . Google Scholar CrossRef Search ADS PubMed 3. Rohrich RJ , Rios JL , Smith PD , Gutowski KA . Neck rejuvenation revisited . Plast Reconstr Surg . 2006 ; 118 ( 5 ): 1251 - 1263 . Google Scholar CrossRef Search ADS PubMed 4. McCollough EG . The McCollough facial rejuvenation system: a condition-specific classification algorithm . Facial Plast Surg . 2011 ; 27 ( 1 ): 112 - 123 . Google Scholar CrossRef Search ADS PubMed 5. DiBernardo BE . Randomized, blinded split abdomen study evaluating skin shrinkage and skin tightening in laser-assisted liposuction versus liposuction control . Aesthet Surg J . 2010 ; 30 ( 4 ): 593 - 602 . Google Scholar CrossRef Search ADS PubMed 6. DiBernardo BE . Treatment of cellulite using a 1440-nm pulsed laser with one-year follow-up . Aesthet Surg J . 2011 ; 31 ( 3 ): 328 - 341 . Google Scholar CrossRef Search ADS PubMed 7. Duck FA. Physical Properties of Tissue . London : Academic Press ; 1990 : 320 - 328 . 8. Sarnoff DS . Evaluation of the safety and efficacy of a novel 1440nm Nd:YAG laser for neck contouring and skin tightening without liposuction . J Drugs Dermatol . 2013 ; 12 ( 12 ): 1382 - 1388 . Google Scholar PubMed 9. Sasaki GH . Early clinical experience with the 1440-nm wavelength internal pulsed laser in facial rejuvenation: two-year follow-up . Clin Plast Surg . 2012 ; 39 ( 4 ): 409 - 417 . Google Scholar CrossRef Search ADS PubMed 10. Hunstad JP . Tumescent and syringe liposculpture: a logical partnership . Aesthetic Plast Surg . 1995 ; 19 ( 4 ): 321 - 333 . Google Scholar CrossRef Search ADS PubMed 11. Caplin DA , Perlyn CA . Rejuvenation of the aging neck: current principles, techniques, and newer modifications . Facial Plast Surg Clin North Am . 2009 ; 17 ( 4 ): 589 - 601 , vi. Google Scholar CrossRef Search ADS PubMed 12. McMenamin P . Laser face-lifts: a new paradigm in face-lift surgery . Facial Plast Surg . 2011 ; 27 ( 4 ): 299 - 307 . Google Scholar CrossRef Search ADS PubMed 13. Gentile RD . Laser-assisted neck-lift: high-tech contouring and tightening . Facial Plast Surg . 2011 ; 27 ( 4 ): 331 - 345 . Google Scholar CrossRef Search ADS PubMed 14. Badin AZ , Moraes LM , Gondek L , Chiaratti MG , Canta L . Laser lipolysis: flaccidity under control . Aesthetic Plast Surg . 2002 ; 26 ( 5 ): 335 - 339 . Google Scholar CrossRef Search ADS PubMed 15. Goldman A . Submental Nd:YAG laser-assisted liposuction . Lasers Surg Med . 2006 ; 38 ( 3 ): 181 - 184 . Google Scholar CrossRef Search ADS PubMed 16. DiBernardo BE , Reyes J . Evaluation of skin tightening after laser-assisted liposuction . Aesthet Surg J . 2009 ; 29 ( 5 ): 400 - 407 . Google Scholar CrossRef Search ADS PubMed 17. McBean JC , Katz BE . A pilot study of the efficacy of a 1,064 and 1,320 nm sequentially firing Nd:YAG laser device for lipolysis and skin tightening . Lasers Surg Med . 2009 ; 41 ( 10 ): 779 - 784 . Google Scholar CrossRef Search ADS PubMed 18. Orringer JS , Rittié L , Baker D , Voorhees JJ , Fisher G . Molecular mechanisms of nonablative fractionated laser resurfacing . Br J Dermatol . 2010 ; 163 ( 4 ): 757 - 768 . Google Scholar CrossRef Search ADS PubMed 19. Brandt FS , Boker A . Botulinum toxin for rejuvenation of the neck . Clin Dermatol . 2003 ; 21 ( 6 ): 513 - 520 . Google Scholar CrossRef Search ADS PubMed 20. Matarasso A , Matarasso SL , Brandt FS , Bellman B . Botulinum A exotoxin for the management of platysma bands . Plast Reconstr Surg . 1999 ; 103 ( 2 ): 645 - 652 ; discussion 653. Google Scholar CrossRef Search ADS PubMed 21. Kane MA . Nonsurgical treatment of platysma bands with injection of botulinum toxin a revisited . Plast Reconstr Surg . 2003 ; 112 ( 5 ): 125S - 126S . Google Scholar CrossRef Search ADS PubMed 22. White WM , Makin IR , Slayton MH , Barthe PG , Gliklich R . Selective transcutaneous delivery of energy to porcine soft tissues using Intense Ultrasound (IUS) . Lasers Surg Med . 2008 ; 40 ( 2 ): 67 - 75 . Google Scholar CrossRef Search ADS PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Aesthetic Surgery JournalOxford University Press

Published: May 15, 2018

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