Nonexcisional, Minimally Invasive Rejuvenation of the Neck

Abstract

•This paper describes nonexcisional techniques for neck rejuvenation.•External and subcutaneous and subdermal laser, RF, light, ultrasound and injectable treatments are reviewed. Editor Commentary: Steve and I have been involved in several emerging technologies and have had the pleasure to discuss alternative and additive modalities with him frequently. In this chapter, Steve takes us on the journey of minimally invasive and non-invasive energy based techniques to rejuvenate the aging neck. He frequently combines these techniques with open aggressive procedures. Realizing that minimally invasive techniques can provide measureable skin tightening has provided yet another opportunity to answer our patients’ desires for procedures with a quicker recovery. Of course these can be stand alone procedures or performed along with or following more aggressive surgical maneuvers. The patient with minimal submental and or jowl laxity after a face and necklift looks to us to provide a solution. For sure, we enjoy surgery more than our patients and therein lies their quest for an easy answer without surgical expense and downtime. Western civilization is experiencing a “boom in boomers,” an aging population, with population decline. The aging population in Western Europe, North America, and Asia has disposable income and the mantra of “youth and vitality” has this generation increasingly presenting for aesthetic treatments, specifically noninvasive or nonexcisional procedures.1US Census Bureau Selected characteristics of baby boomers 42 to 60 years old in 2006. US Census Bureau, Washington2006Google Scholar, 2Moretti Michael Skin tightening; softening demand in a weak economy. Medical Insight Inc, Aliso Viejo, CA2008Google Scholar The neck aesthetic subunit often ages early and more noticeably than other head and neck regions and is one of the most common motivations for patients to present to aesthetic physicians for rejuvenation options. The neck undergoes extrinsic and intrinsic aging changes in all anatomic layers and the aesthetic physician must be well equipped to deal with aging cervical concerns, both surgically and nonsurgically. For the surgeon, being skilled in nonsurgical cervical rejuvenation is critical, as many patients may opt for nonexcisional cervical enhancements, alone, or in combination with other facial cosmetic surgical procedures. For the cervical surgeon, a familiarity and expertise with nonsurgical management of the neck, as “stand-alone” therapy or as postoperative “protect your investment” treatments, may help extend and prolong the achievements achieved surgically. A youthful neck is most often characterized by an acute cervicomental angle and a firm, well-defined jawline (Fig. 1). The skin in a youthful neck is smooth and devoid of horizontal or vertical neck lines; has no platysmal bands; no visible submandibular glands; small, nonhypertrophic masseter muscles; and skin that is bright and even in color, with minimal melanin or vascular lesions.3Feldman J. Neck lift. Quality Medical Publishing Inc, St Louis (MI)2006Crossref Google Scholar For the nonexcisional cervical physician, aesthetic rejuvenation of the neck with a multimodal, nonexcisional, minimally invasive approach will be a very common and popular component of the facial aesthetic practice. For all aesthetic physicians, familiarity with the aging tissue changes of the neck, its anatomy and the possible minimally invasive, nonexcisional interventions, including laser, light, radio frequency, high-intensity focused ultrasound (HIFU) energy-based therapy, both transepidermal and subdermal approaches, injectable soft tissue fillers, neuromodulators, and ablative and nonablative technologies for skin rejuvenation, as well as suture-based suspensory techniques, all used alone or in combination, will be a valuable asset to the global aesthetic head and neck cosmetic physician. This article brings together the “tried-and-true” nonexcisional neck rejuvenation methodologies, which have had long-term, peer-reviewed success in the literature, together with procedures and technologies that have emerged in the past few years that have proven to be successful and complementary. It is my hope that this information assists aesthetic physicians in enhancing their global approach to nonexcisional rejuvenation of the neck. This issue of Clinics in Plastic Surgery deals extensively with the surgical options and management of the aging neck. However, the noninvasive, minimally invasive and nonexcisional solutions for the neck are often what patients opt for and, many times, are techniques and strategies that can also enhance and/or extend surgical results, or can be applied following surgical neck procedures to provide smaller enhancements and maintenance of the outcome postoperatively. The aesthetic anatomy of the neck can be divided into several layers, from superficial to deep, starting with the skin, subcutaneous tissue, superficial musculo-facial layer and deep subplatysmal structures (Fig. 1).3Feldman J. Neck lift. Quality Medical Publishing Inc, St Louis (MI)2006Crossref Google Scholar In this section, the relevant anatomy of the neck as it pertains to minimally invasive and noninvasive rejuvenation procedures is outlined and then cervical enhancement options for each layer follow. The anatomic classification of the neck pertains to the aging structures as the patient sees them and to the anatomic options and targets that the aesthetic physician may elect to treat, which are outlined in Fig. 2. The cutaneous layer of the neck consists of a relatively thin epidermis and dermis. The skin of the neck is subject to multiple mimetic and cervical animations, and tensile and compressive loads. Bending the neck in the anterior-posterior direction, as well as side to side with active contraction of the underlying platysma, can lead to horizontal lines or “necklace lines.” The skin ages as a consequence of intrinsic (genetic) and extrinsic (applied) forces. The neck itself is often exposed to the sun and may not be protected by sunscreen and, thus, often presents with significant extrinsic photoaging. Cervical photoaging will result in increased epidermal thickness, degeneration of functional elements of the cervical dermis, such as useful collagen, elastin, and ground substances, with accumulation of whorls of elastotic collagen in the deep dermis (Fig. 3). Aging laxity of the platysmal muscle may lead to visible central and/or lateral neck bands. The cumulative photoaging of the neck combined with intrinsic aging and mimetic changes results in a typical aging cutaneous cervical envelope, characterized by thin “crepe” skin, diffuse dyschromia and telangiectasia, with multiple vertical lines in the midline, affectionately termed “iguana neck,” as well as horizontal lines, centrally and laterally, attributed to platysma and cervical motion (see Fig. 3). The aesthetic physician needs to be especially skilled in the rejuvenation of the cutaneous layer of the neck. Surgeons performing excisional neck surgery can often fail to deliver optimal neck rejuvenation results by not being familiar with, or equipped to deal with, superficial aging changes of the neck. The superficial cutaneous aging changes to the neck do not respond optimally to pure tensile repositioning characterized by neck lift surgery, but rather, respond to multimodal, noninvasive treatments designed to improve the more superficial color, tone, and texture of the skin. Similarly, nonsurgical aesthetic physicians need to familiarize themselves with the various nonexcisional treatment modalities used to rejuvenate the cutaneous layers of the aging neck. Deep to the cutaneous, epidermal-dermal layer of the neck is subcutaneous or adipose tissue. There can be a wide variation in aging presentations of the cervical subcutaneous layer. Some patients have aging cervical phenotypes that have little subcutaneous fat between the deep dermis and the underlying platysma, whereas other patients have extensive amounts of subcutaneous fat between the dermis and the platysma. Modest-to-large amounts of subcutaneous fat will create an obtuse angle to the cervicomental angle and detract from what is considered a youthful neck. An ideal neck consists of a vertical cylinder, the trachea and muscles that connect as a right angle to the floor of the mouth and submandibular tissue, forming a 90° angle (see Fig. 1). Subcutaneous fat of the neck is generally less fibrous than adipose tissue of the trunk or thighs and is a single layer with interlobular fascial components connecting the platysma layer on its deep surface to the dermis. It is imperative that the aesthetic physician be able to diagnose subcutaneous fat, which is preplatysmal, from subplatysmal fat, which will also compromise the acute cervicomental angle, but is more difficult to access and to treat without incisional or excisional surgery. The platysma bands are wide, broad strap-shaped skeletal muscles extending from the clavicle to the dermal attachments along the mandibular border.3Feldman J. Neck lift. Quality Medical Publishing Inc, St Louis (MI)2006Crossref Google Scholar The cervical platysma is invested by the superficial layer of the deep cervical fascia and will extend superiorly as the superficial-muscular aponeurotic system (SMAS).3Feldman J. Neck lift. Quality Medical Publishing Inc, St Louis (MI)2006Crossref Google Scholar The platysma comes in a number of anatomic variants, including those with no central diastasis and those with a wide central diastasis that may present as medial platysmal bands. The platysma itself has been attributed the aesthetic function of a secondary depressor of the modiolus, synergetic to the primary depressor of the corner of the mouth, the depressor angularis oris (DAO), and in this fashion, the lateral platysmal bands can act as a depressor of the midface, commissure, mouth, and jawline.4Carruthers A. Carruthers J. Cosmetic uses of botulinum exotoxin.Adv Dermatol. 1997; 12 (Vancouver, Canada: Mosby-Year Book Inc): 325-347PubMed Google Scholar, 5Carruthers J. Carruthers A. The adjunctive usage of botulinum toxin.Dermatol Surg. 1998; 24: 1244-1247PubMed Google Scholar The platysma itself, when hypertonic, can lead to distracting aesthetic contours, causing obliquity of the otherwise youthful, acute cervicomental angle (see Fig. 3). With aging and muscle flaccidity and atrophy, the platysma bands can contribute to cervical laxity, creating a loose, adynamic, and obtuse neck. The aesthetic physician should be prepared to treat the cervical platysma when it is aesthetically important to the an optimal rejuvenative outcome, and excisional physicians, in addition to surgical manipulation and excision transection techniques, must also be able to manage nonoperatively any dynamic preoperative and postoperative cervical aesthetic problems. The subplatysmal aesthetic structures that can be treated nonexcisionally or minimally invasively include the densely packed, subplatysmal, adipose tissue that is present in a significant proportion of cervical aesthetic patients, as well as the submandibular glands. The deeply compacted subplatysmal fat lies on top of the mylo-hyoid muscle and may contribute to a “double chin” or obtuse cervicomental angles, and the aesthetic physician needs to be able to diagnose, either by clinical examination or ultrasound techniques, when the submental fat is due to preplatysmal or subplatysmal pathology. Suctioning subplatysmal fat may require a small incisional localization of the platysma to place the cannula in the subplatysmal plane, or open subplatysma lipectomy. The other deep platysmal structures that occasionally require aesthetic management and nonexcisional treatment are the submandibular glands. The submandibular glands measure approximately 3 × 5 cm and are secondary salivary glands that rest in the lateral floor of the mouth and they can occasionally be visible as lumps or soft tissue shadows in the lateral neck. These glands can be particularly visible postoperatively after tightening or suction reduction procedures of the anterior and lateral neck. Both the excisional and nonexcisional cervical aesthetic physician needs to be able to address prominent submandibular glands (see Fig. 3). Melanin discoloration, or dyschromia, of the neck is common, given its sun-exposed location on the head and neck region. Commonly patients will neglect to apply sunscreen or sunblock on their cervical region, yet cover the backs of their hands and their face. Over years of sun exposure, the typical photoaging appears. Melanin and dyschromia lesions can range from isolated solar lentigines or diffuse dyschromia and melisma. Diffuse brown discoloration is a very common presentation of the aging neck. Quite frequently, the dyschromia is associated with other signs of photoaging, including thickening and hyperkeratosis of the epidermis layer, thinning dermis with decreased elasticity, decreased functional elastin and collagen, and elastotic whorls of disorganized collagen in the deep reticular dermis associated with fine or deep cervical rhytides (see Figs. 2 and 3). The cervical skin will often look vertically fissured or, even further, cobblestoned Fitzpatrick VIII, IX, or X type of rhytids can appear (see Figs. 2 and 3). The dyschromia, with or without photoaging is best treated with modalities that are either specific to the discoloration or nonspecific and ablative in nature. Historically, chemical peels of the neck, like complete laser ablative resurfacing, were fraught with potential for wound-healing complications, as the adnexal tissue in the cervical dermis is limited, with few sebaceous glands, pilosebaceous units, eccrine, or apocrine glands to reepithelialize completely ablated skin.6Schwartz R.J. Burns J. Rohrich R.E. et al.Long term assessment of CO2 facial laser resurfacing: aesthetic results and complications.Plast Reconstr Surg. 1999; 103: 593-601Google Scholar, 7Bernstein L.J. Kauvar A.N. Grossman M.C. et al.The short and long-term side effects of carbon dioxide laser resurfacing.Dermatol Surg. 1997; 23: 519-525Crossref PubMed Scopus (335) Google Scholar Hence, the use of moderate strength office or home-based topical chemical correction of cervical dyschromia has become popular, with very mild chemical peels or “bleaching agents.”8Olsen E.A. Katz H.I. Levine N. et al.Tretinoin emollient cream for photodamaged skin: results of 48-week, multicenter, double-blind studies.J Am Acad Dermatol. 1997; 37: 217-226Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar, 9Kang S. Leyden J.J. Lowe N.J. et al.Tazarotene cream for the treatment of facial photodamage. A multicenter, investigator-masked, randomized, vehicle-controlled, parallel comparison of 0.01%, 0.025%, 0.05% and 0.01% taxarotene creams with 0.05% tretinoin emollient cream applied once daily for 24 weeks.Arch Dermatol. 2001; 137: 1597-1604Crossref PubMed Google Scholar The bleaching regimens generally consist of combinations of retinoic acids 0.05% to 0.1%, or tazarotene 0.025% to 0.01%, alone or combined with hydroquinone 4%, 6%, or 8%, 4% Kogic acids, and occasionally mild hydrocortisone-compounded substances. Prescriptive skin bleaching programs include the popular Tri-Luma. Other skin care regimens, such as Obagi, SkinCeuticals, Physician Choice of Arizona, Skin Medica, and others, have been quite popular in gradually bleaching dyschromia of the neck using home-based programs. Office-based treatments include stronger chemical peels, although the risk of delayed reepithelialization and hypopigmentation or hyperpigmentation is greater when stronger preparations of glycolic, glycolic acid, trichloroacetic acid, or stronger topical chemical ablatives are deployed. Over the past 15 years, chromophore-based lasers and light-based sources have become the mainstay of skin color correction and are arguably the gold standard of dyschromia-associated aging of the neck. Chromophore-based lasers and light-based systems have wavelengths of light that are specifically attracted to intra-epidermal, epidermal-dermal, and superficial dermal melanin, through a process called selective photothermolysis.10Anderson R.R. Parish J.A. Selective photothermolysis: a precise microsurgery by selective absorption of pulsed radiation.Science. 1983; 220: 524-527Crossref PubMed Scopus (2735) Google Scholar Typically, wavelengths in the range of 500 to 800 nm will have some increased affinity for and selective absorption of superficial cervical melanin-based concerns. Some of the monochromatic focal wavelengths for the improvement of superficial epidermal-dermal melanin include the 532-nm wavelength Potassium titanyl phosphate (KTP) lasers, 694.5 nm Q-switched Ruby, and the 755 long-pulsed or Q-switched Alexandrite lasers, which have all been deployed in specific correction of dyschromia of the neck.11Sadick N.S. Alexiades-Armenakas M. Bitter P.H. et al.Enhanced full face skin rejuvenation using synchronous intense pulsed optical and conducted bipolar radiofrequency energy (ELOS): introducing selective radiophotothermolysis.J Drugs Dermatol. 2005; 4: 181-186PubMed Google Scholar, 12Zelickson B.D. Kilmer S.L. Bernstein E. et al.Pulsed dye laser for sun damaged skin.Lasers Surg Med. 1999; 25: 229-236Crossref PubMed Scopus (222) Google Scholar, 13Weiss R.A. Goldman M.P. Weiss M.A. Treatment of poikiloderma of civatte with an intense pulsed light source.Dermatol Surg. 2000; 26: 213-218Google Scholar Pulsed dye lasers in the 585-nm wavelength have also been deployed to treat not only vascular lesions but pigmented lesions of the neck.12Zelickson B.D. Kilmer S.L. Bernstein E. et al.Pulsed dye laser for sun damaged skin.Lasers Surg Med. 1999; 25: 229-236Crossref PubMed Scopus (222) Google Scholar However, the one most popular light-based rejuvenation of the neck for dyschromia and vascular chromophores has become intense pulsed light, or IPL.14Bitter P.H. Non-invasive rejuvenation of photodamaged skin using serial, full-face intense pulsed light treatments.Dermatol Surg. 2000; 26: 9Google Scholar, 15Bitter P.H. Goldman M.P. Non-ablative skin rejuvenation using intense pulsed light.Lasers Surg Med. 2000; 28: 12-16Google Scholar IPL, broad-band flash lamps, or xenon flash lamps consist of visible wavelengths of light from 500 nm to 1200 nm all released during the same pulse. Specific cutoff filters are deployed in a variety of methods, with or without direct water cooling, interpositional gel, or air cooling in a multitude of intense pulsed light systems available on the market to treat very effectively melanin and vascular discoloration of the cervical skin. Generally, for cervical rejuvenation in skin types I, II, and III, with dyschromia, cutoff filters in the 515-nm to 580-nm range have been very successful.14Bitter P.H. Non-invasive rejuvenation of photodamaged skin using serial, full-face intense pulsed light treatments.Dermatol Surg. 2000; 26: 9Google Scholar, 15Bitter P.H. Goldman M.P. Non-ablative skin rejuvenation using intense pulsed light.Lasers Surg Med. 2000; 28: 12-16Google Scholar For skin types 4 and 5, long wavelength cutoff filters in the 590-nm to 640-nm ranges, lower energies, and longer pulse configurations have allowed the treatment of darker discoloration in patients with more advanced Fitzpatrick skin type.16NegisThi K. Tezuka Y. Kushikata N. et al.Photorejuvenation for Asian skin by intense pulsed light.Dermatol Surg. 2001; 27: 627-632Crossref PubMed Scopus (157) Google Scholar Using gentle energy with broad melanin absorption coefficients and overlapping 20% or so, each pulse can provide safe, effective clearance for even the most severe cervical dyschromia over several sessions. Intense pulsed light treatments of the neck usually require 1 treatment every 3 to 4 weeks for a total of 3 to 5 treatments. It can be quite common to cause striping in the neck following early IPL therapy in patients with extensive photoaging, which is caused by a combination of aggressive settings and not overlapping the light guide sufficiently during each treatment, which results in aggressive fading of the treated neck adjacent to untreated skin that does not fade in color. Gentle settings, multiple sessions, and overlapping or crisscrossing can avoid this problem. It is important that the IPL settings are gentle moderate in fluence, as IPL may induce a permanent hypopigmentation or discoloration of the skin.13Weiss R.A. Goldman M.P. Weiss M.A. Treatment of poikiloderma of civatte with an intense pulsed light source.Dermatol Surg. 2000; 26: 213-218Google Scholar, 14Bitter P.H. Non-invasive rejuvenation of photodamaged skin using serial, full-face intense pulsed light treatments.Dermatol Surg. 2000; 26: 9Google Scholar, 15Bitter P.H. Goldman M.P. Non-ablative skin rejuvenation using intense pulsed light.Lasers Surg Med. 2000; 28: 12-16Google Scholar Monochromatic treatment of the neck with focal monochromatic laser systems can cause a reticulated hypo-pigmented appearance to the cervical skin.13Weiss R.A. Goldman M.P. Weiss M.A. Treatment of poikiloderma of civatte with an intense pulsed light source.Dermatol Surg. 2000; 26: 213-218Google Scholar It is common in dyschromia and photoaging of the skin to have a relative white and protected area of skin color immediately under the chin and submentum superior to the hyoid cartilage. This “white patch” represents the shaded area naturally created by the projected pogonion of the mandible. It is important to try to blend the “white under chin” into the more dyschromic and photoaged, lateral, and inferior aspects of the neck. It is also important to blend the discoloration of the central and lateral neck into the posterior triangle and trapezius border. Additionally, carrying the treatment over the clavicle onto the precordial region will help minimize risk of demarcation between a treated neck and an untreated décolleté. Often, combining complete cervical dyschromia correction with décolleté will provide a natural blend between the rejuvenated neck, the chest, and the face (see Fig. 3). The recent addition of fractional nonablative, fractional ablative lasers, and ablative fractional radiofrequency devices has also provided an opportunity to improve dyschromia and photoaging, as well as fine lines and texture of the neck.17Manstein D. Herron G.S. Sink R.K. et al.Fractional photothermolysis: a new concept for cutaneous remodeling using microscopic patterns of thermal injury.Lasers Surg Med. 2006; 34: 426-438Crossref Scopus (1179) Google Scholar, 18Geronemus R.G. Fractional photothermolysis: current and future applications.Lasers Surg Med. 2006; 38: 169-176Crossref PubMed Scopus (275) Google Scholar, 19Bass L.S. Rejuvenation of the aging face using fraxel laser treatment.Aesthet Surg J. 2005; 25: 307-309Crossref PubMed Scopus (20) Google Scholar, 20Daniel D. Bernstein L.J. Geronemus R.G. et al.Successful treatment of acneiform scarring with CO2 ablative factional resurfacing.Lasers Surg Med. 2008; 40: 381-386Crossref PubMed Scopus (252) Google Scholar, 21Chapas A.M. Brightman L. Sukai S. et al.Successful treatment of acneiform scarring with CO2 fractional resurfacing.Lasers Surg Med. 2008; 40: 382-386Google Scholar, 22Gotkin R.H. Sarnoff D.S. Cannarozzo G. et al.Ablative skin resurfacing with a novel microablative CO2.J Drugs Dermatol. 2009; 8: 138-144PubMed Google Scholar, 23Rahman Z. Tanner H. Tournas J. et al.Ablative fractional resurfacing for the treatment of photodamage and aging.Lasers Surg Med. 2007; 39: 15Crossref Google Scholar, 24Hruza G. Taub A.F. Collier L.S. et al.Skin rejuvenation and wrinkle reduction using a fractional radiofrequency system.J Drugs Dermatol. 2009; 8: 259-265PubMed Google Scholar Although intense pulsed light and other monochromatic melanin-based wavelengths of light are very effective for brown and red “color correction,” they have little effect on fine rhytides and wrinkles and the use of ablative fractional carbon dioxide lasers, and, to a lesser extent, ablative fractional and nonfractional erbium lasers can have the simultaneous benefit of decreasing the dyschromia and improving fine lines, rhytides, and laxity.17Manstein D. Herron G.S. Sink R.K. et al.Fractional photothermolysis: a new concept for cutaneous remodeling using microscopic patterns of thermal injury.Lasers Surg Med. 2006; 34: 426-438Crossref Scopus (1179) Google Scholar, 18Geronemus R.G. Fractional photothermolysis: current and future applications.Lasers Surg Med. 2006; 38: 169-176Crossref PubMed Scopus (275) Google Scholar, 19Bass L.S. Rejuvenation of the aging face using fraxel laser treatment.Aesthet Surg J. 2005; 25: 307-309Crossref PubMed Scopus (20) Google Scholar, 20Daniel D. Bernstein L.J. Geronemus R.G. et al.Successful treatment of acneiform scarring with CO2 ablative factional resurfacing.Lasers Surg Med. 2008; 40: 381-386Crossref PubMed Scopus (252) Google Scholar, 21Chapas A.M. Brightman L. Sukai S. et al.Successful treatment of acneiform scarring with CO2 fractional resurfacing.Lasers Surg Med. 2008; 40: 382-386Google Scholar, 22Gotkin R.H. Sarnoff D.S. Cannarozzo G. et al.Ablative skin resurfacing with a novel microablative CO2.J Drugs Dermatol. 2009; 8: 138-144PubMed Google Scholar, 23Rahman Z. Tanner H. Tournas J. et al.Ablative fractional resurfacing for the treatment of photodamage and aging.Lasers Surg Med. 2007; 39: 15Crossref Google Scholar, 24Hruza G. Taub A.F. Collier L.S. et al.Skin rejuvenation and wrinkle reduction using a fractional radiofrequency system.J Drugs Dermatol. 2009; 8: 259-265PubMed Google Scholar More recently, fractional radiofrequency devices, such as the Fractora (Invasix, Yokneam, Israel), have become available, which can provide variable depth and variable density needle-based tips for fractional ablative improvement of the dyschromia of the neck, as well as the textural improvements that can be equivalent to those achieved with carbon dioxide.25Mulholland R.S. Ahn D.H. Kreindel M. et al.Fractional radio-frequency resurfacing in Asian and Caucasian skin: a novel method for deep radiofrequency fractional skin resurfacing.J Chem Dermatol Sci Appl. 2012; 2: 144-150Google Scholar At the same time, the Fractora delivers a nonablative, non-necrotic tightening of the cervical region. The Fractora delivers radiofrequency energy and a positive charge along each of the pins in the needle array, resulting in an ablative crater and a zone of nonablative, but irreversible, thermal coagulation. Following the ablative injury, the radiofrequency (RF) energy then flows from the tip of the pin to the negative side electrode, creating a rich woven network of nonablative RF dermal heating, tightening, and remodeling (Fig. 4, Fig. 5, Fig. 6).25Mulholland R.S. Ahn D.H. Kreindel M. et al.Fractional radio-frequency resurfacing in Asian and Caucasian skin: a novel method for deep radiofrequency fractional skin resurfacing.J Chem Dermatol Sci Appl. 2012; 2: 144-150Google ScholarFig. 5High power histology showing fractora fractional RF ablative injury, with re-epithelialization and remodeling.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig. 6The family of variable length and variable density Fractora tips.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Complications of the management of melanin and dyschromia of the neck include scars from overzealous laser and light-based settings, hypopigmentation from aggressive settings that result in a complete or near-complete clearance of melanocytes, as well as demarcation from treated and untreated areas.6Schwartz R.J. Burns J. Rohrich R.E. et al.Long term assessment of CO2 facial laser resurfacing: aesthetic results and complications.Plast Reconstr Surg. 1999; 103: 593-601Google Scholar Quite often, clinically, dyschromia occurs together with vascular discoloration, such as in Poikiloderma of Civatte, which is covered in the next section. In addition to dyschromia and melanin-based lesions, it is quite common to get superficial vascular proliferation as a part of extrinsic photoaging or intrinsic genetic aging of the neck. The vascular proliferation derived from photoaging responds very nicely to the intense pulsed light with the same cutoff filter spectrum mentioned in the dyschromia section.11Sadick N.S. Alexiades-Armenakas M. Bitter P.H. et al.Enhanced full face skin rejuvenation using synchronous intense pulsed optical and conducted bipolar radiofrequency energy (ELOS): introducing selective radiophotothermolysis.J Drugs Dermatol. 2005; 4: 181-186PubMed Google Scholar, 14Bitter P.H. Non-invasive rejuvenation of photodamaged skin using serial, full-face intense pulsed light treatments.Dermatol Surg. 2000; 26: 9Google Scholar, 15Bitter P.H. Goldman M.P. Non-ablative skin rejuvenation using intense pulsed light.Lasers Surg Med. 2000; 28: 12-16Google Scholar Occasionally, deep dermal and subdermal, proliferative vascular lesions occur in the neck and monochromatic long-pulse or variable pulsed wavelengths, such as long-pulsed neodymium-YAG or short-pulse and long-pulse, pulsed dye lasers are required.12Zelickson B.D. Kilmer S.L. Bernstein E. et al.Pulsed dye laser for sun damaged skin.Lasers Surg Med. 1999; 25: 229-236Crossref PubMed Scopus (222) Google Scholar The combination of reticulated hyperpigmentation and vascular proliferation in the upper papillary and mid-dermis condition, called “Poikiloderma of Civatte,