How Do I Fix Sagging Neck Skin?

September 4, 2020

Featured Physician: Sabrina Fabi, MD

Featured Article:  How to Get a Smoother, Firmer Neck

Dr. Sabrina Fabi is a world-renowned Cosmetic Dermatologist and Board-Certified physician. She is a Diplomate of the American Board of Dermatology and the American Board of Cosmetic Surgery.  Dr. Fabi is a pre-eminent clinician and researcher, focusing her research on cosmetic and laser treatments. As an internationally recognized leader in cosmetic dermatology, she is featured prominently in the media and recently contributed to an article on anti-aging treatments for the neck in Good Housekeeping magazine. She joins us today to share some of her knowledge on approaches to treating and preventing aging of the neck.

What Happens to Your Neck as You Age?

myDoqter: Dr. Fabi, thank you for joining us to discuss problems of the aging neck. This traditionally has been a very tough area to treat for a number of reasons we will discuss, but there are a lot of great new treatments and preventative strategies today. Can you start by sharing with us what you hear from patients about what bothers them the most about the aging neck?

Dr. Fabi: Yes, the neck is a very common area of concern. Patients’ complaints include skin laxity, sagging, and the quality of the skin, which tends to look more crepey with time. In addition, there may be excess fat deposits in the areas of the jowls, as well as the submental fullness under the chin.

Why Are Neck Wrinkles So Challenging to Treat?

myDoqter: The anatomy of the neck area is a very important consideration as well, and there can be significant structural changes in this area that can contribute to aging.  Can you discuss some of these findings that you tend to see?

Dr. Fabi: In addition to fat accumulations that I discussed above, there is an element of bone resorption (loss of bone mass) that contributes to loss of definition of the jawline and neck area. The platysma is a muscle that attaches to the mandible and extends down, as a ‘drape’ to the level of the clavicles. This muscle may lose some of its support from the mandible over time. What we can see during aging is the formation of platysma banding that pulls down on the face. So, as you can see, treatment of the neck is a complex issue, as it relates to more than just the aging of the skin. It involves the fat, muscle tissue, as well as bone loss. It’s a multiple tissue process.

myDoqter: Indeed, that is why this area has been such a challenge to treat. Are there qualities of the skin itself in this area that would change your approach versus other areas such as the face?

Dr. Fabi: Yes, the first thing that is different is the thickness of the skin. The neck is much thinner and, even within the neck area, there can be variations in skin thickness and fat thickness. The skin can be as thin as half of one millimeter, especially on the lower neck. And there can be large amounts of fat accumulation in the upper neck, while there is small amount of fat in the lower neck. This means that there is a very intimate connection between the muscle and skin in the lower neck, as opposed to the upper neck. There also may be prominent muscle and nerve structures that the treating physician needs to be aware of when rejuvenating the neck.

Additionally, the skin of the neck has fewer pilosebaceous units. These are the follicle structures that each contain a tiny hair (‘pilo’) and an associated oil gland (‘sebum’). Normally, it is from this structure that the skin sends in new signals and cells for skin regeneration in the event of a burn, an injury or even a well-controlled laser treatment. They are the structures that normally allow the skin to heal. Since the skin of the neck naturally has fewer of these pilosebaceous units, its healing potential is lower, and so our approach to treating the neck must be more refined and delicate.  We cannot be as aggressive with our treatments on the neck because of the potential for scarring.

What Creams Help an Aging Neck?

myDoqter: Those are great points. As far as topical treatments, what are your recommendations for the neck area?

Dr. Fabi: I always tell patients that just like the face, they should not forget to apply sunblock on the neck to prevent the fragmentation of collagen and elastic fibers that is caused by ultraviolet rays. The neck has less of a reservoir of collagen because the skin is so much thinner.

I also advise washing with an alpha hydroxy acid cleanser to remove particulate matter and superficial dead skin cells from the skin. In the morning, I advise using Skin Medica Total Defense and Repair with sunblock and antioxidants, or you can use a general mineral sunblock with Vitamin C, Vitamin E, and ferulic acid.

In the evening, you can use retinols or retinoic acid on the face, and gradually work them down on to the neck, if you can tolerate them well in this area. But they may be too irritating at times for the neck, so growth factors formulations are a great alternative to provide the building blocks for collagen, elastic fibers and other components of the skin.  TNS serum is a great product with both growth factors and anti-oxidants all in one.

Laser Neck Tightening

myDoqter: Ok great!  Let’s turn to laser and energy-based devices for neck rejuvenation. What are your favorite treatments for this area?

Dr. Fabi: I choose the best laser depending on what I am treating:

  • For color tones, like excess brown pigment or redness, I like to use the Intense Pulse Light, also known as IPL. This is commonly called the “photofacial” and it address the unevenness of the skin. This treatment will also stimulate collagen in the superficial part of the skin, called the dermis.
  • For more texture and collagen stimulation, I can combine the IPL with non-ablative laser on the same day. To stimulate collagen, we can use devices like the Clear and Brilliant 1440-nm diode laser or the Fraxel laser.  Studies support that combining the IPL with laser treatments on the same day is more effective when treating the aging skin of the neck.
  • Finally, if there is redness and more crepiness with deeper or more etched-in lines, which we often see in Southern California, we can use a vascular laser and/or IPL, followed by the fractionated CO2 laser. This is an ablative laser and is more deeply penetrating than the non-ablative ones discussed above. But in the neck, the CO2 laser must be used with more conservative settings and may require more sessions to achieve significant results.

myDoqter: That is a great summary of treating the more superficial aspects of the skin discoloration and texture. What about neck tightening? The superficial treatments may help to some degree, but what are your recommendations for deeper tightening?

Dr. Fabi: In those cases where there are excess pockets of fat and there is also a need for skin tightening, I use subsurface monopolar radiofrequency devices like THERMItight to tighten the skin, and combine it with micro-liposuction to remove the excess fat. This type of device is able to heat up the superficial layer (fascia) that sits right on the muscle, so you can see the contraction along the mandible.

If there is excess fat on the neck, but the patient does not want to undergo a liposuction procedure, we can use injectable Kybella to ‘melt’ the fat, or CoolSculpting to non-invasively freeze and eliminate the excess fat of the neck.  In some cases, we use a combination approach with the CoolSculpting first, as long as there is enough fat to fit in the cup of the CoolSculpting applicator. We then transition over to Kybella, as the fat is reduced. I usually space treatments 3 months apart.

Thread Lifts for Neck Rejuvenation

myDoqter: What about non-surgical approaches to neck lifting? Botox is a commonly used treatment to relax the platysma muscle which is responsible for the ‘neck bands’, but are there other options?

Dr. Fabi: I do perform thread lifts in order to lift the neck, but I rarely do them on the neck alone. When I do treat the neck alone with threads, I limit treatment to the upper neck. However, most of the time, I treat the neck in conjunction with the face. We must bear in mind that the neck is not so forgiving when it comes to the thread lift procedure. This is because the fat layer under the skin is very thin on the neck and yet we want to make sure that the threads are not visible under the skin. So a lot of the thread lifting of the lower face and neck must be done by placing the threads together in the lower face and upper neck.

Five Top Tips to Prevent Neck Aging

myDoqter: Thank you Dr. Fabi for a detailed and thorough approach to rejuvenating the neck. To finalize, what would be your top 5 recommendations to prevent aging of the neck area.

Dr. Fabi: My top 5 tips to prevent neck aging would be:

  1. Start using a daily mineral block early (these contain zinc oxide and/or titanium dioxide)
  2. Don’t forget to wash your neck when you wash your face, morning and evening
  3. Use a topical growth factor to boost collagen on the neck
  4. Consider IPL in your 20s to maintain an even tone
  5. Incorporate non-ablative lasers like the Clear & Brilliant in your 30’s


Non-Surgical Neck Rejuvenation with combination approach: Thread Lifting, Lasers and Submental Fat Removal.


To learn more about Dr. Sabrina Fabi, visit:


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