PracticalDermatology

For a time, surgery and/or liposuction were the only ways to get rid of unwanted pockets of fat in the once-neglected submental region, but today there are at least two noninvasive modalities that specifically target double chins and can be used alone or together.

Kybella (deoxycholic acid) injections cause necrosis of submental fat, and CoolSculpting’s CoolMini applicator freezes under-chin fat cells to apoptosis.

The key is matching the correct treatment or treatments with the correct patient.

In general, these therapies are best for non-obese individuals who simply have a deposition of fat under the chin. These treatments are real home-runs for young people who have a genetic predisposition to fat underneath the chin. By contrast, patients who have loose and redundant skin under their chin and neck are weaker candidates for these therapies, as they target fat, not laxity. In older patients, the platysma muscle can be unmasked when fat is removed, so caution is advised. However, even non-optimal candidates can be improved with both therapies as long as the patients are adequately informed and have realistic expectations.

Kybella vs. CoolSculpting

Kybella and CoolSculpting each have their own set of benefits and drawbacks. Kybella can treat small areas of fat, does not require a capital investment, and can be done in a small exam room. This short (10-12 minutes) and simple treatment is also relatively painless and may tighten skin because of the cell necrosis and subsequent inflammatory process.

CoolSculpting, by contrast, can debulk bigger necks, treat lateral areas, and involves less downtime than Kybella. It can also be easily delegated to physician extenders and may be less expensive for the patient.

The disadvantages of Kybella include three days of downtime due to extreme initial swelling, higher possible cost for the patient, as well as the potential need for more treatments. In addition, these injections can’t be used to treat the lateral area of the neck without a new nerve stimulator that mark outs the mandibular nerve so it can be avoided. At a recent Allergan advisory board meeting that I attended, however, many adept and experienced practitioners of Kybella injection stated that they had significant experience injecting lateral necks without having side effects. In addition, they feel that many practitioners are undertreating, and when patients understand the permanent nature of the therapy, they are willing to undergo some down time.

Unlike Kybella, CoolSculpting requires a substantial investment in capital equipment and a larger treatment room due to the size of the device. Treatment takes 45 minutes per applicator. If both sides of the jawline are treated in one session, treatment can last up to 1.5 hours. CoolMini can induce claustrophobia in some patients. Also, the neck fat needs to be a specific size and shape to be vacuumed into the applicator.

I recommend cryolipolysis for large necks that extend laterally and for debulking and opt for Kybella to treat mild to moderate necks and for those patients who might be claustrophobic. In some cases, a combination of the two technologies can produce an even more impressive result. I may introduce Kybella after CoolSculpting for a more finished look and to reduce what is left, which may be too small for the CoolMini applicator. Sometimes I will combine neuromodulator injections to relax the playtsmal bands and/or a tightening device such as Ultherapy to improve laxity for results that are closer to what can be achieved with a surgical neck lift. Combination therapy tends to be optimal in most aesthetic scenarios.

Dr. Taub originally presented this talk during Cosmetic Surgery Forum 2016 in Las Vegas. Cosmetic Surgery Forum 2017 will be held November 29–December 2, 2017. Register now

Amy Forman Taub, MD is the Medical Director and Founder of Advanced Dermatology/skinfo, with offices in Lincolnshire and Glencoe, IL. She is also an assistant clinical professor of dermatology at Northwestern University Medical School.

Dr. Taub is a Consultant (Medical Advisory Board): DUSA/Sun, Medicell Technologies, Sterilis Medical Corporation, Suneva; Honoraria: Suneva, Kythera, Allergan, SkinMedica, Aclaris, DUSA, Syneron/Candela, PCA Skin; Speaker: DUSA/Sun, Kythera, Suneva, Syneron/Candela; Equity: MediCell Technologies LLC, Sterilis Medical Corporation, skinfo.