A youthful neck is an important element of beauty; therefore, the restoration of the neck and décolletage is an integral part of facial rejuvenation. These areas are most vulnerable to sun damage and depict the signs of photoageing very early. Resurfacing of the skin plays an essential role in the rejuvenation process, but the deeper structures also often need attention. Although commonly associated with ageing, a significant proportion of younger patients never have, but seek, a defined cervical angle. In the context of neck recontouring, soft tissue characteristics have a wider variation, and impose their limitations on surgical management. There are many tools available in the armamentarium of aesthetic practice to treat the neck and décolletage. Successful management depends on appropriate patient selection and suitability of the treatment to address the patient’s concerns and wishes. A range of resurfacing techniques with surgical intervention will help to maximise the outcome and lead to higher patient satisfaction.

The surface landmarks of the neck begin at the inferior border of the mandible superiorly, supraclavicular area inferiorly, and the anterior border of the trapezius laterally. Below the skin is the fat compartment, which is an essential component relevant to the aesthetics of the neck. The fat is distributed in the subcutaneous and subplatysmal planes of the neck. The amount and distribution is affected by age, gender, ethnicity and pathological process1, 2. The platysma originates from the fascia overlying the pectoralis and deltoid muscles. The fibres of the muscle pass superiorly, attach to the mandible, and intermingle with the facial muscles. These paired muscles decussate in the middle of the neck and the muscle is classified according to the extent of decussation. With ageing, splaying of the medial portion of the platysma leads to dynamic bands on anterior neck3, 4. The superficial musculoaponeurotic system (SMAS) continues in the neck as superficial fascia and envelopes the platysma. The main neurovascular structure lies deep to the platysma (i.e. jugular veins, carotid artery, cervical plexus and cranial nerves). Other structures relevant to the aesthetics of the neck include the paired digastric and mylohyoid muscles, and the submandibular gland. The upper chest, breast, neck and shoulders are collectively referred to as the décolletage. The skin in this region is very sensitive and vulnerable to photodamage. The anatomical features and planes present in the neck are not very distinct in the décolletage area.

Clinical assessment

Clinical assessment of the patient is the initial step in the process of rejuvenation. The quality of the skin, laxity, extent of photodamage and pattern of pigmentation should be evaluated. More in-depth analysis includes assessment of the levels of adipose tissue distribution in different planes of the neck. The assessment is carried out both in static and dynamic states. Depending on the clinical findings, the neck can be categorised into different groups. A number of classification systems have been developed to grade the ageing neck and the treatment protocol is planned accordingly5, 6. Photographic documentation with anterior, lateral and oblique views is essential for a complete assessment. Three dimensional analysis of the neck can provide valuable information with regard to characteristics of the skin, submental volume, and the relationship to the bony structures.

Management of the neck and décolletage can be broadly classified into surgical and non-surgical methods. These modalities are often combined to achieve better outcomes.

Non-surgical approaches

Non-surgical rejuvenation can be applied as a single treatment method, or in combination with invasive methods. Non-surgical interventions are usually applied first when rejuvenating the neck and décolletage. These techniques aim to improve the elasticity and tone of the skin, restore moisture and radiance, and to manage fine lines and wrinkles.