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Journal of Drugs in Dermatology, Oct, 2009 by Patricia Guedes Rittes, Clarissa Rites

ABSTRACT

Background: The lower third of the face and neck have distinct changes that occur with aging: the lost of the perfect jaw line due to laxicity of skin and fat deposits associated with “turkey neck.” Theses changes can be globally and drastically addressed with traditional rhytidectomy, however patients increasingly seek less invasive procedures. Injections with Lipostabil–a mixture of phosphatidylcholine and deoxycholate, a bile salt–have been used to reduce unwanted, accumulated fat. Recent in vivo investigations indicate that phosphatidylcholine and deoxycholate cause adipocyte lysis, an inflammatory processes and fibrosis. These reactions lead to skin retraction.

Objective: This paper reports the author’s experience treating aging neck using Lipostabil Endovena.

Results: Laxity of the skin improved in all patients. A marked reduction in double chins was noted and the jaw line was reconstructed. Adverse effects, including transient burning, erythema and local swelling were present in all patients, but resolved themselves without intervention.

Conclusion: The author’s clinical experience supports the conclusion that Lipostabil Endovena treats subcutaneous fat tissue and that fibrosis after the inflammatory process retracts the skin, tightening the injected area and improving the aging neck.

INTRODUCTION

The aging neck is a common complaint in dermatological and plastic surgery offices. The lower third of the face and neck have distinct changes that occur with aging: the lost of the perfect jaw line due to laxicity of skin and fat accumulation associated with what is called “turkey neck.”

Treatment traditionally includes surgical excision or liposuction, depending on the characteristics of the laxity. Although effective, these treatments are associated with surgical risks, scarring and hematomas. Treatments that are minimally invasive and not associated with these risks would be ideal for patients reluctant to undergo surgery but who wish to improve the appearance of their necks.

Several open-label clinical trials have reported localized loss of adipose tissue using subcutaneous injections of a mixture containing phosphatidylcholine, a bile salt, and sodium deoxycholate as an excipient, (1), (2), (4-6) which is used to solubilize the soy lecithin-derived phospholipid (Lipostabil[R] Endovena).

Recent experimental investigation demonstrates that this mixture has a detergent action that produces fat cell lysis, necrosis and a desired inflammatory process. (3) The evolution of these processes might lead to fibrosis, which would be seen clinically as skin retraction.

In this article, a case study is presented of patients treated with subcutaneous injections using Lipostabil Endovena as a treatment for aging neck.

METHODS

After obtaining written informed consent for treatment, 15 patients with clinically diagnosed aging chins were injected with Lipostabil Endovena (250 mg/mL phosphatidylcholine). The medical histories reported by patients were not relevant, nor had the patients had previous interventions in the neck area. The same clinician who performed the injections also evaluated neck laxity and used pre-and post-treatment photographs to document the changes.

A 30-gauge 0.5-in needle attached to a 5 mL syringe was used to directly inject the solution subcutaneously into the subcutaneous fat. No ice or topical anesthetic was used. Patients were treated with 0.3 mL of solution at three sites located at the mid-jaw line on the left and right and under the middle of the chin. No pressure was applied directly to the sites of the injections and an elastic band was recommended for use the first two nights.

The patients’ clinical responses were recorded, including pain and erythema immediately after injection. Additional reactions occurring in the intervals between treatments were recorded by patients and reported during the subsequent visit. Intervals between injections were at least two weeks in length. Treatment consisted of one to four sessions. The study conformed to the guidelines of the 1975 Declaration of Helsinki.

RESULTS

A total of 15 patients with aging neck: 14 women and one man, aged 36-57 years of age with Fitzpatrick skin type 2-4, were injected with Lipostabil Endovena; observations are summarized in Table 1 and Figures 1-3.

All patients presented reduced aging neck after a mean of 2.6 treatments (seven patients were treated two times; six patients were treated three times and two patients were treated four times). The time interval between treatments ranged from two weeks to three months due to a number of factors unrelated to clinical response or treatment.

Notably, most patients treated experienced moderate burning within minutes of injection and mild sustained, localized swelling (two weeks). Ecchymoses occurred in two patients, both of whom bled at the injection site. No patient reported constitutional symptoms at any time during treatment.

Cosmetic improvement occurred in all patients. Pre- and post-procedure photographs were utilized to document the changes, as shown in Figures 1-3. All patients complained of a mild burning sensation following injections, typically lasting about 15 minutes. Immediately following the injections, infiltrative edema and local erythema were noted over the initial six hours and persisted for approximately 72 hours. All patients were followed for 1.5 years after the last treatment.

DISCUSSION

The procedure documented in this study offers a non-surgical alternative for improving the aging neck by reducing the excess of skin in this area.

The injections of Lipostabil Endovena contain phosphatidylcholine, which is typically combined with deoxycholate to facilitate suspension of the phospholipids in an aqueous solution. Deoxycholate is a secondary bile salt that has been incorporated as an emulsifier in intravenous medication. This detergent action was recently shown to produce human keratinocyte cell lysis in vitro (4) and the combination of both (Lipostabil Endovena) shows necrosis of adipose in rabbits in vivo. (3)

Based on this, the author presumes that after injection intensive necrosis occurred in the fat tissue, followed by an inflammatory process. This process would likely lead to fibrosis, which would be seen clinically as skin retraction. Patients may prefer minimally invasive procedures, even if the outcomes are less dramatic than more invasive techniques.

The safety of this procedure is based on 15 years experience injecting Lipostabil endovena inside the fat and the complications of this use was published in a recent retrospective study. (7),(8) The cosmetic results observed were satisfactory from the point of view of both the patients and the treating dermatologists. This study supports the use of a simple, non-surgical office-based procedure for treating aging neck.

Long-term follow up has reached the two-year mark with no return of local fat as long as there is no weight gain (over 4 kg).

DISCLOSURES

The authors have no relevant conflicts of interest to disclose.

REFERENCES

(1.) Rittes PG. The use of phosphatidylcholine for correction of lower lid bulging due to prominent fat pads. Dermatol Surg. 2001; 27(4):391-392.

(2.) Rittes PG. The use of phosphatidylcholine for correction of localized fat deposits. Aesthetic Plast Surg. 2003;27(4):315-318.

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