Chemical peels

Chemexfoliation, or chemical peels, are powerful tools that are widely used to treat skin affected by the signs of ageing and photodamage. Some of the indications for chemical peels include rhytides, pigmentation changes, scars, actinic skin changes, and acne. The peel is carried out using a range of chemical substances, and can be broadly classified into superficial, medium and deep exfoliation peels. The depth of the peel is determined by the peeling agent, concentration, skin type and anatomical area to be treated. Superficial peels act on the epidermis to provide light exfoliation. These are mainly carried out using AHAs such as glycolic and lactic acid. Superficial peels can be used to treat photodamage, hyperpigmentation and provide superficial exfoliation. Salicylic acid, which is a BHA, can promote deeper sloughing. It is often combined with resorcinol and lactic acid as Jessner’s solution. The peels are started at a low concentration and can be increased to provide deeper penetration.

Medium-depth peels act on the epidermal to papillary dermis, while deep peels reach the reticular dermis to induce dermal regeneration. Medium and deep peels are performed using a variety of concentrations of trichloroacetic acid (TCA) and phenol. Pre-treatment of the skin may be necessary to achieve good results, especially with deep peels. Chemexfoliation of the skin should be used very carefully on the neck and décolletage to resurface the skin and treat superficial wrinkles, pigmentation, and actinic keratosis. Superficial peels can be performed safely; careful selection of patient and suitability of the product to the skin type is indispensable to prevent unwanted complications15, 16.

Lasers and photorejuvenation

Lasers and intense pulsed light (IPL) therapy are well accepted forms of minimally-invasive rejuvenation. A variety of photosensitisers and diverse light sources have been used to treat pigmentation, fine lines and elasticity of the ageing skin. An increasing number of lasers with new technology are being introduced to the market with a wider safety margin and minimal complications. However, using laser technology to treat the neck and décolletage can be difficult.

Pigment changes and scarring are well acknowledged complications of ablative lasers, especially in the neck region17, 18. Innovations with regard to fractional lasers, however, have revolutionised the facial rejuvenation process. Fractional lasers create microthermal zones by delivering columns of thermal injury to the skin. Therefore, confluent epidermal damage is prevented and recovery is good owing to the presence undamaged epithelial cells. Fractional lasers can be combined with broadband light to provide fractional photorejuvenation of the neck and décolletage. Collective use of optical energy with radiofrequency (RF) provides deeper penetration of the dermis
and facilitates new collagen formation and remodelling. The combined energy is used synergistically to achieve photorejuvenation and moderate tightening of the skin
19, 20.

Figure 1 Improvement in appearance of photodamage to the décolletage using cosmeceutical formulations (Obagi Medical), (A) before and (B) 8 weeks post-treatment

Figure 1 Improvement in appearance of photodamage to the décolletage using cosmeceutical formulations (Obagi Medical), (A) before and (B) 8 weeks post-treatment

Mesotherapy and PRP

Platelet rich plasma (PRP) and mesotherapy are also effective options for the rejuvenation of the neck and décolletage. The true clinical value and efficacy of these modalities are yet to be established. PRP is a relatively new innovation in the management of aesthetic skin rejuvenation. It is a matrix of fibrin and platelets derived from the patient’s own blood. When injected into the skin, the growth factors activate the fibroblasts and help to stimulate collagen production. The effect of PRP has been proven by a number of clinical studies21, 22, and the impact of tissue healing and skin rejuvenation has been studied extensively. The therapy can be used either alone or in combination with other treatment modalities, such as fractional lasers21–23.

Mesotherapy is a technique used to revitalise the skin by transdermal injection of multivitamins, hyaluronic acid, and natural plant extracts. When injected into the skin, these components are claimed to stimulate fibroblast activity and facilitate collagen and elastin production. There are a number of methods of injection into the skin, which include intradermal, papular and nappage techniques. In the nappage technique the skin is pricked rapidly and gently to deposit the solution. The needle is directed at 45° to rapidly inject small amounts of the solution. In the papule technique the solution is injected very superficially into the skin in small amounts and at regular intervals. The needle is dragged along the skin while applying light pressure. This is usually carried out in a grid pattern, and a MesoGun can be used, which can provide faster injections with precise dose delivery. In the intradermal technique, the solution is injected intradermally.Mesotherapy is an accepted form of treatment to rejuvenate the neck and décolletage. Even though this is a popular form of therapy, there is currently limited evidence to support the clinical and histological changes on the skin24–26.