LAUSR

The increasing consumer demand for minimally invasive or noninvasive procedures has driven a burgeoning industry of technological advances that cater to this desire. Neck adiposity is an emerging area of interest, driven in large part by the US Food and Drug Administration’s clearance of injectable deoxycholic acid in April 2015, along with a juggernaut of related marketing endeavors. As surgeons, we must always be wary of noninvasive methods that might make bold claims, using surgical methods of cervical fat reduction as the criterion standard by which to judge any new entrants into the competitive field. However, we must also embrace methods that may undoubtedly serve as adjuncts, alternatives, or replacements for surgical techniques when they are truly viable. With that spirit, I commend the article in this issue of JAMA Facial Plastic Surgery on submental cryolipolysis by Bernstein and Bloom,1 who have sought to quantifiably evaluate both the aesthetic improvement and the patients’ subjective perception of their results and the nature of their experience. The article serves to expand the current limited body of literature exploring this new application of cryolipolysis.2 One of my major concerns with any type of nonsurgical neck lipolysis is the apparent reduction of fat but the potential for aesthetic worsening of the neck’s appearance by revealing such flaws as platysmal banding or skin irregularities. In my practice, I hold an arbitrary cutoff age of candidacy for a patient of 40 years to undergo any kind of isolated neck lipolysis (whether surgical or nonsurgical) because I fear that the neck will reveal such flaws. I lower that age for individuals with poor neck tone and already incipient visibility of flaccid muscle banding. I increase that age for individuals who have very full neck fat (thereby increasing the margin of safety) and good skin tone— features typically more prevalent in patients of nonwhite races/ ethnicities. In fact, when I undertake removal of fat in the neck, I do so using sharp scissor dissection rather than with a suction wand (which I have not used for about 10 years). By opening the neck through submental incision, I can visualize the excess fat and very selectively remove the offending fat in a judicious manner, leaving a cuff of fat over the platysma muscle to disguise it and to target areas that would benefit from reduction such as the cervicomental angle and the convex portion of the submental region. I like to call this procedure selective neck lipocontouring rather than liposuction, as it more accurately represents what I do and why I do it. Evaluating the 3 clinical photographs from the study by Bernstein and Bloom,1 I notice that there is increased visible platysmal banding in all 3 patients and noticeable skin irregularities in 2 of the 3 patients. The question that arises, then, is whether fat reduction has truly aesthetically improved the patient’s appearance. One can argue that the patients in the study expressed a high degree of satisfaction and that that should be a proper end point. I would argue the contrary, to say that the physician’s aesthetic judgment should serve as the foundation for any decision-making process. Personally, I much prefer a fuller neck than one that exhibits more platysmal visibility, which is a greater sign of aging. Despite the quantifiably improved skin tightening results in the study by Bernstein and Bloom,1 I would argue that the presence of platysmal banding would suggest the contrary (ie, more overall neck flaccidity). Another important point is the nature of the recovery that is involved for these nonsurgical lipolytic methods, both deoxycholic acid injection and cryolipolysis. If one major intent of nonsurgical methods is to reduce downtime, then the question must be raised if these nonsurgical methods may actually engender the opposite. With deoxycholic acid and cryolipolysis, multiple sessions are often needed, with each treatment requiring a notable window of recovery. The study by Bernstein and Bloom1 does a good job of detailing the nature and extent of the recovery, and I think patients should be well educated about their options, with a frank discussion of cumulative downtime and associated cost for the procedure and time away from work. Accordingly, it would be interesting to see a future article comparing these patient-centric concerns for each treatment method, such as deoxycholic acid vs cryolipolysis, or cryolipolysis vs surgical neck lipocontouring, or any combination of these treatments. Applying technology from the body to the head and neck area can be very revealing because it exposes a new set of aesthetic criteria along with different aesthetic goals. A wellknown criticism leveled against body cryolipolysis is that the results can be subtler (especially with a single treatment session) than with body liposuction. Perhaps this criticism will be less of an issue with the very confined and limited area of fat that needs to be reduced in the submental region. Similarly, the use of deoxycholic acid may not be as fruitful for larger body contouring owing to the requirement for a much higher volume of product, but that will be seen. In novel approaches such as reduction of small lipomas, deoxycholic acid may be showing promise to reduce the risk of scarring, especially in the body, and more studies are warranted to evaluate the role of these nonsurgical methods of lipolysis in various clinical scenarios. Another area about which I am curious is the degree to which subplatysmal fat can be reduced with these nonsurgical methods without risking a cobra-type deformity or other adverse events. As a strong proponent of nonsurgical techniques in my armamentarium, I am always hopeful and excited about new technological breakthroughs, but I am also cautiously optimistic, having seen too many seemingly great techniques disappear after accumulated experience revealed their inadequacies. Not only are more studies along the lines Related article A Cautious but Optimistic Opinion of Submental Cryolipolysis Invited Commentary