Letters and Communications
The demand for treatment of transverse neck lines is increasing as patients pursue rejuvenation that moves beyond the face. Multiple treatment strategies have been reported ranging from the relatively noninvasive use of chemical denervation with botulinum toxin to the most invasive surgical lifting of the superficial musculoaponeurotic system.1 Fractionated laser, radiofrequency, microfocused ultrasound, and dermal fillers have been used for management alone and in combination with published reports describing the use of cohesive polydensified matrix hyaluronic acid (CPM-HA; Belotero Balance; Anteis S.A., Geneva, Switzerland), small-particle HA with lidocaine (SP-HAL; Restylane Vital; Q-Med AB, Uppsala, Sweden), and calcium hydroxylapatite (CaHA; Radiesse; Merz North America, Inc., Raleigh, NC).1–4
The etiology of transverse neck lines is multifactorial and they have not been found solely on individuals with advanced age.3 The lines are observed in individuals of all ages, including infants, and we hypothesize that retention fibers likely play a role in their etiology. A validated scale has recently been created to assess transverse neck lines with standardized grading.1
Contraction of the platysma can exacerbate the lines as can loss of skin elasticity and decrease in collagen synthesis. The suspected role of platysmal contraction explains the benefit seen with neuromodulators. Although dermal fillers have been used to add volume to the lines, the potential for nodules, however transient, provides a less desirable outcome.2,3 Injection of calcium hydroxylapatite into the lines too superficially has led to beading along injection sites, which ultimately resolved with introduction of saline and massage.2 Thus, selection and placement of the appropriate dermal filler is paramount. Filler injections using a cannula to correct transverse neck lines have never been reported.
The recently approved hyaluronic acid (HA) gel with lidocaine (VYC-15L; Juvederm Volbella XC; Allergan, Inc., Dublin, Ireland) for lip augmentation and correction of perioral rhytides may be more malleable and softer relative to other fillers. However, its use for transverse neck lines has never been reported, and it was therefore selected for a trial treatment for this indication using a cannula.
Cohesive polydensified matrix hyaluronic acid (Belotero Balance; Anteis S.A., Geneva, Switzerland) is a cohesive, homogenous gel with zones of greater and lesser cross-linking density.5 Studies suggest that it more uniformly integrates into the dermis, making it a fitting selection for the filling of fine lines.5 Recent evidence from our group demonstrates the consistent and durable improvement of a range of etched-in facial fine lines.5 In an attempt to see if the findings from the face will translate off the face and onto the neck, a trial using this product for management of the etched-in transverse rhytides was performed using a cannula.
We present the pre- and post-treatment photographs from patients treated in one session trials with either VYC-15L or CPM-HA as the sole intervention for transverse neck lines.
Our first patient is a 37-year-old woman with a single transverse neck line for which she had no previous treatment (Figure 1). VYC-15L was injected directly into the transverse fine line using a 2-inch, 22-gauge cannula. The cannula was inserted subdermally on each end of the transverse neck line. VYC-15L was slowly injected from the most lateral aspect of the neck line to the medial aspect using a threading technique. Approximately 1.5 mL was injected into the transverse neck line in total. After introduction of the filler into the defect, the product was gently massaged with a cotton tip applicator. At the 2-, 6-, and 12-week follow-up visits, exceptional improvement of transverse neck lines was noted and the patient reported high satisfaction with the treatment. At the 2- and 6-week follow-up visits, some of the treated areas demonstrated mild lumping. The lumping corresponded only to areas treated with the bevel of the needle facing superiorly, with a more superficial injection technique. All lumpiness had resolved at the 12-week visit (Figure 2). There were no other injection site reactions noted.
The second patient is a 51-year-old man with 2 transverse neck lines for which he had no previous treatment (Figure 3). One mL of CPM-HA in total was introduced into the immediate subdermal plane of the transverse lines with a 1.5-inch, 27-gauge cannula using the same technique as performed with the previous patient. The patient tolerated the procedure well without complication and was highly satisfied with the treatment. Follow-up images were taken slightly over 5 weeks after treatment and the patient remained satisfied with the results at that visit (Figure 4).
These cases demonstrate that effacement of the transverse neck lines can be achieved solely with injection of a dermal filler with the appropriate rheologic properties. The treatments were well tolerated and the only observed injection site reaction was mild lumpiness with the VYC-15L, which resolved by the 12-week follow-up visit. To avoid overcorrection and lumpiness, we advise placement of the bevel downward during the injection and not inject too superficially. The treatment with CPM-HA demonstrates that the findings with etched-in lines on the face can translate to treatment of transverse neck lines. In both cases, use of a cannula in lieu of a needle allows for less injection points and the potential for decreased risk of postinjection bruising. It is possible that there is underlying subcision afforded by the use of a cannula that may help release underlying retention fibers that contribute to the formation of these lines. Further studies are warranted to evaluate the safety, effectiveness, and longevity of both filler agents for the treatment of transverse neck lines.
1. Jones D, Carruthers A, Hardas B, Murphy DK, et al. Development and validation of a photonumeric scale for evaluation of transverse neck lines. Dermatol Surg 2016;42(Suppl 1):S235–S42.
2. Chao Y, Hui-Hsien C, Howell D. A novel injection technique for horizontal neck lines correction using calcium hydroxylapatite. Dermatol Surg 2011;37:1542–5.
3. Lee SK, Kim HS. Correction of horizontal neck lines: our preliminary experience with hyaluronic acid fillers. J Cosmet Dermatol 2017;00:1–6.
4. Vanaman M, Fabi SG, Cox SE. Neck rejuvenation using a combination approach: our experience and a review of the literature. Dermatol Surg 2016;42:S94–S100.
© 2018 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.
5. Black JM, Gross TM, Murcia CL, Jones DH. Cohesive polydensified matrix hyaluronic acid for the treatment of etched-in fine facial lines: a 6-month, open-label clinical trial Dermatol Surg 2018;44:1002–11.