When subtle isn't enough

Dr. GoldmanThe neck is one of the most challenging parts of the body for cosmetic surgery to address, and a dermatologist told an audience of colleagues that they shouldn't settle for subtle contouring results.

"If you want to achieve a beautiful neck, you really have to go to extremes," says Mitchel P. Goldman, M.D., volunteer clinical professor of dermatology at the University of California at San Diego. "If we really want to achieve meaningful results, we have to think about more aggressive procedures."

Dr. Goldman, also medical director at Cosmetic Laser Dermatology, spoke at the 2016 CalDerm Symposium, a continuing education seminar offered by the California Society of Dermatology & Dermatologic Surgery.

More heat, more pain, more results

What does being more aggressive mean in terms of neck procedures? When it comes to contouring, Dr. Goldman says, heat produces tightening through inflammation, so a bolder approach can be better.

"There are lots of ways to put heat into the skin. The key part of this is, the more aggressive you are, the more pain you cause. The more heat you put in, the more of a wound you're going to get, and the better result. That’s reality."

What about techniques? Micro-focused ultrasound is one option.

"You definitely get an improvement," Dr. Goldman says. "But this is something that's really not a one-time procedure." He adds that the procedures cost thousands of dollars, raising questions about whether they're worth the cost for patients.

"You have to go into this knowing that you’ll have a percentage of patients who won’t be happy," he says. "But you do get home runs. Some patients get very good results. It tends to work on patients who are a bit younger, healthier, who exercise more, who have more skin elasticity."

Next: Studies mixed on micro-focused ultrasound

Studies mixed on micro-focused ultrasound

In terms of research, Dr. Goldman points to a recent study he co-authored (Dermatol Surg. 2014 May;40(5):569-75) that showed slight improvement from micro-focused ultrasound treatment for lifting and tightening the face and neck.

The retrospective study examined 48 female patients, average age 58 (range 39-85), who received micro-focused ultrasound with visualization (MFU-V) full-face treatment following 5.0 PLUS guidelines. Physician assessment of photos at baseline and 6 months (44 patients) saw "slight improvement" in neck skin laxity from 2.56 (on a 0-5 scale) to 2.18, a greater result (-0.38) than for lower-face (-0.24) and mid-face (-0.20). Upper-face had the best result:  -0.55 on the 5-point scale.

Dr. Goldman pointed to another study (J Drugs Dermatol. 2016 May 1;15(5):607-14) that examined the use of MFU-V at two focal depths to lift and tighten skin laxity in 64 subjects. (Average age 55, range 39-65, 95% female, 89% white).

Of 61 patients who reached 180-day follow-up, blinded physicians rated 29 improved and 10 at no change. They rated another 22 as improved but failed to correctly differentiate between pre- and post-treatment images. Results were similar after an analysis of 60-day results with 19 subjects removed due to poor-quality images. 

The research links more aggressive treatment to better results, Dr. Goldman says. But pain is an issue, he says, and it can't be resolved with ibuprofen.

“We try to minimize pain with the use of intramuscular Demerol and Phenergan and also oral Valium,” he says. 

Another alternative: Kybella

Dr. Goldman suggests two other treatments for neck contouring: Kybella (deoxycholic acid) and Botox.

Kybella does produce results, he says, but it can require many treatments and "patients get this incredible edema that can last for upwards of a week. Even though it's easy to do and literally takes me five minutes to treat a patient, they go through this edema."

In addition, he says, injections can cause ulcerations, and "it's not idiot-proof" because there's a risk of a thrombus that produces an ulceration if it's injected into a blood vessel. But Dr. Goldman says he's been working on an off-label Kybella blend that shows promise in eliminating pain and edema by reducing inflammation. Future studies will offer insight, he says.

Disclosures: Dr. Goldman reports that he has conducted clinical studies and received discounted equipment from Ulthera/Merz, Solta, Thermi, and Kythera/Allergan.