The décolletage—or the area comprising the neck, chest and shoulders—is one of the areas of the body most prone to ageing. This is because of the thin skin in this area, combined with the weight of the breasts and UV damage. Yet despite this, in our everyday lives, many of us do not protect the décolletage effectively. When applying sun protection, we regularly apply to the face, neck and even hands, but the décolletage is often forgotten. This means that in the summer months, the area is exposed to the sun's rays without protection.
When it comes to body enhancing aesthetic treatment, the décolletage is also often overlooked. Many patients and practitioners will focus solely on enhancing the face, forgetting that a sun-damaged décolletage can undermine the enhancements they have undergone elsewhere on the body.
When considering the changes that happen in the décolletage area as the patient ages, it can be useful to divide these changes into three main categories:
Vascular changes are typically visible with women with Fitzpatrick Skin Types 1 and 2 and they can range from a few scattered spider nevi to a more extensive network of capillaries that create redness in the whole area.
Pigmentation changes can be visible in all skin types, and are sometimes called age spots or liver spots. In Fitzpatrick Skin Types 1 and 2, they can just be normal freckles. Some patients experience not only hyperpigmentation, but also hypopigmentation, which can create a patchy and uneven look. Some of the pigment can also become raised with time and turn into solar keratosis.
Textural changes usually contribute to the grainy appearance of the skin, which can be more visible in certain lights and in the cleavage area. Textural changes to the décolletage area include moles and raised lesions, but mainly include the lines that are seen in the area, which usually radiate from the cleavage to the collar bones. Textural changes appear differently in different women, and are more likely to appear in women with a larger bust and those who like to sleep on their side.
Treatment
Each of these types of changes to the décolletage requires a different treatment, and it is therefore important to establish during the consultation which changes are affecting the patient the most, in order to plan the best course of treatment possible.
Treating structural changes
In the past, the lines in the décolletage area have often been treated by injecting them with dermal fillers, but there is a fine balance between eliminating those lines and overfilling them, which can give the lines a raised appearance and make them more obvious than they were before treatment.
Radiofrequency devices
In recent years, new radiofrequency devices have been introduced to treat a variety of skin conditions, particularly skin wrinkling and laxity. These systems work by inducing tissue tightening through a process of dermal collagen remodelling, and increasing the production of collagen (Alster and Lupton, 2007). The most difficult structural change to treat is the grainy appearance of the décolletage area, which usually precedes the lines and is often first visible in the cleavage. However, more recently, radiofrequency devices are used in the whole of the décolletage area to improve not just the lines, but also the overall texture of the skin (Bohnert et al, 2018; Elawar and Dahan, 2018). Non-ablative radiofrequency skin tightening treatment can stimulate collagen production and improve the appearance of wrinkles.
Radiofrequency has been around for several years, and there are many devices that deliver it externally through a probe that a practitioner slides on the skin with the help of a gel. However, the invention of microneedling applications of radiofrequency in recent years means that the energy can now be delivered straight to the target—the deep dermis—and studies have shown this approach to be effective in treating facial photoageing (Zhang et al, 2018). When used on the facial area, radiofrequency treatment has produced noticeable clinical results, with high satisfaction and corresponding facial skin improvement, indicated by a statistically significant increase in the mean of collagen types I and III (el-Domyati et al, 2011).
A study by Mulholland et al (2012) found the use of radiofrequency devices to be safe and effective in skin rejuvenation treatment. They found that the treatment:
A study by Hellman (2015) assessed one such device and concluded that it had a very good impact on acne scarring. A second study by the same author (Hellman, 2016) showed further improvement in scarring up to 75/80%, despite patients having no additional treatments after this point. These results are encouraging, as if the treatment can help scars, it is thought that it can also help deep lines and wrinkles, which are effectively types of scars.
For best results, a course of 6 treatments is recommended.
Treating vascular changes
Light sources, IPL and laser
Vascular changes in the décolletage are usually treated using light sources, IPL or laser procedures. Light-based treatments have affinity to the colour of the skin, and the best treatment candidate will be one that has a pale background skin and a bright red lesion. Therefore, an active suntan is an absolute contraindication for treatment. The best candidates are Fitzpatrick Skin Types 1–3. After treatment, the patient will often experience bruising and swelling of the treated area, and the patient should take measures to protect the area from the sun after the treatment. Usually, more than one session is required to achieve a good result.
Pigmented lesions in the décolletage can also be treated using lasers and IPL, which have an affinity to the brown pigment, rather than red. However, the same principle applies, which is that there should be a big contrast between target (lesion) and the patient's background skin. As such, an active suntan or Fitzpatrick Skins Types 3–6 are an absolute contraindication to treatment, as treatment in such cases could lead to burns. In the décolletage, this could lead to scarring and hypopigmentation.
Topical preparations and chemical peels
Another treatment option for melasma in the décolletage area is topical preparations, in the form of mild chemical peels. Chemical peels are classified by the depth of action into superficial, medium, and deep peels. The depth of the peel is correlated with clinical changes, with the greatest change achieved by deep peels. However, deep peels are also associated with longer healing times. Superficial peels only penetrate the epidermis, and can be used to treat a variety of conditions, including acne, melasma and photodamage (Rendon et al, 2010).
Mild chemical peels can be used to treat age-related changes in the decolletage, but should be treated with great care, as healing in the décolletage area is not as efficient as on the face; therefore, there is a greater risk of chemical burns in this area. A peel that is suitable for treating the decolletage is glycolic acid peels, also known as ‘cellular peels’, as the acid works at a cellular level, shocking cells and causing them to shed (McGloin, 2018). The peeling process with milder peels is slower, so several treatments may be needed. The glycolic solution should be prepared to suit the patient's particular skin type and then brushed over the décolletage and left on for approximately 10 minutes. Following this, the solution should be rinsed off with water, and a moisturising lotion and sun block should be applied.
According to McGloin (2018), the following factors must be considered before treating any patient with a chemical peel:
Skin should be prepared for treatment for a minimum of 2 weeks prior to treatment, using an AHA cleanser, retinol (vitamin A) or a skin lightening agent, such as hhydroquinone of kojic acid (McGloin, 2018).
Medium and deep chemical peels are not suitable for treating the décolletage. In cases where the treatment has not given sufficient outcomes, it is recommended that several milder peels are used, rather than one deeper peel. As with any treatment, taking a complete history prior to applying a peel is critical.
Patients should be given comprehensive aftercare advice, including instructions to avoid the sun for the days after treatment and to apply SPF to the treated area.
Conclusion
The decolletage area is often overlooked by patients and practitioners. However, to achieve a holistic approach to rejuvenation, this area should be given due consideration. First, the practitioner should establish whether the changes in the decolletage are vascular or structural. Then, the practitioner should work with the patient to determine a suitable treatment plan. With due consideration of this area, the patient can be given a more holistic treatment to truly rejuvenate their appearance.