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When treating the lower face and neck, 'don't forget the platysma muscle'.

SAN DIEGO -- Of all the data points featured in a 2017 survey on cosmetic dermatologie procedures, one stands out to Jean Carruthers, MD: Among the 7,322 consumers surveyed, about 70% cited the lower face and submental contour as a significant cosmetic and social concern.

"That is quite a key statistic," she said at the annual Masters of Aesthetics Symposium. The Consumer Survey on Cosmetic Dermatologie Procedures was conducted by the American Society for Dermatologie Surgery.

Dr. Carruthers, who, with her husband, Alastair Carruthers, MD, pioneered the cosmetic use of onabotulinumtoxinA (Botox), said that the world's great sculptors "think that there is a difference between the classical faces of males and females, and we all know instinctually what those changes are, with a square face and larger jawline in males and a smooth oval, heart-shaped face in women," she said.

"But what about the neck?" She cited an article by Greg J. Goodman, MD, and colleagues, which defined an ideal neck as the distinct inferior mandibular border from mentum to angle with no jowl overhang (Dermatol Surg. 2016;42:S260-2). It includes subhyoid depression, which visually enhances the impression that the neck is thin and long; visible thyroid cartilage bulge; a visible anterior border of the sternocleidomastoid muscle, distinct in its entire course from the mastoid to the sternum; and a cervicomental angle between 105 and 120 degrees. An angle greater than 120 degrees appears as a double chin or heavy neck, according to the authors.

In the past, clinicians used to think of the lower face and neck as two separate cosmetic units, but now they are considered one cosmetic unit, said Dr. Carruthers, of the University of British Columbia, Vancouver. "Don't forget the platysma muscle," she added. "The platysma is a lower facial muscle of expression and it affects all the other muscles. It interdigitates with the depressor anguli oris, with orbicularis oris, and depressor labii inferioris muscles, and it goes backwards into the masseter muscle."

She and two Brazilian investigators published a retrospective analysis of 161 patients treated by a Botox injection pattern encompassing the facial platysma components, aiming to block the lower face as a whole complex (Dermatol Surg. 2017;43[8]: 1042-9). According to the article, results included "frontal and lateral enhancement of lower facial contour, relaxation of high horizontal lines located just below the lateral mandibular border, and lower deep vertical smile lines present lateral to the oral commissures and melomental folds."

Fillers and tightening the face and neck envelope without surgery takes maintenance, Dr. Carruthers said. She also noted that deoxycholic acid works on jowls as well as submental fat. Noninvasive combinations for lower face and neck include neuromodulators and deep and superficial fillers, cryolipolysis and deoxycholic acid, energy-based devices, and microneedling. "I think that these are fantastic combinations, and they don't have to all be done at the same time on the same day," Dr. Carruthers said. "I'm very impressed with cryolipolysis as the unheralded skin tightener. I looked at our first 464 patients and saw tremendous skin tightening."

Of all the injectable products on the market, she said that neuromodulators "have set a new gold standard for all aesthetic treatments. It's the most powerful primary aesthetic modulator and enhances the result of everything else that you do."

Dr. Carruthers disclosed that she is a consultant to and has received research support from Allergan, Alphaeon, Bonti, Merz, Revance, and Zeltiq.


AT MOAS 2018

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Author:Brunk, Doug
Publication:Dermatology News
Date:Oct 1, 2018
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