Beauty From the Neck Up: Introduction to the Special Issue

The concept of facial beauty is universally and intuitively understood, yet defining beauty is challenging and has been the topic of scholarly discussion for centuries. From an evolutionary perspective, beauty is considered to be an adaptive trait contributing to survival and providing a mechanism to advance a species.1 Beauty is subliminally interpreted as an indicator of a healthy and fertile potential mate. In a sense, it is an advertisement of the superiority of one's genetic makeup. In our society, people perceived to be beautiful are advantaged because of hardwired beliefs that a person's worth is a reflection of his or her beauty.2 Perception of one's own beauty contributes to self-esteem or self-confidence, which then manifests as attractiveness.3 Notwithstanding its universal appeal, the perceptions of ideal beauty and attractiveness are likely colored by cultural factors, as well as cross-cultural influences in an increasingly globalized world.2 Yet, there are universal key factors that contribute to facial beauty, including averageness (koinophilia), symmetry, sexual dimorphism, youthfulness, and flawless skin.2,4 We have a general expectation of what a face should look like, and the closer one's appearance comes to that ideal, the more likely it is to be perceived as beautiful. The features of a beautiful face are different for males and females, and it has been shown that sexually dimorphic features contribute to increased attractiveness in the respective sexes. The shape of the face underlies the factors of its beauty. For females, the ideal youthful facial shape is a smooth oval,5 but for males, a square face is attractive if the upper face is symmetrical and the jawline is strong. Facial symmetry and unblemished skin are perceived as signs of youthfulness and beauty in both males and females. Symmetrical facial features serve as a subconscious indicator of health and fertility based on the premise that resources resulting in symmetry could not have been available to the body until its fundamental needs are fully met.4 Facial symmetry also plays a role in sex identity.6 The chin and jawline contribute to the beauty of the face. In men, a strong chin has been associated with authority, self-confidence, and trustworthiness,7 whereas in women, a small, more youthful chin is desirable. The chin and jawline should be strongly defined as distinct regions separate from the neck. Blurring of this definition may occur with age as a consequence of volume descending from above and from the sides as the angle of the jaw and bony mandible resorb. However, a genetically weak chin and submental fullness due to fat accumulation will also add to this softness and can cause an individual to look overweight and/or older. Given their contribution to overall facial beauty, it is not surprising that the chin and neck tend to be areas of concern for many individuals. For example, a consumer survey conducted by the American Society for Dermatologic Surgery in 2015 found that 67% of respondents (n = 7315) were somewhat to extremely bothered by excess fat under the chin/neck.8 Although not universal or absolute to all cultures and ethnicities, characteristics of an aesthetically pleasing youthful chin and neck have been described as follows9: Distinct inferior mandibular border from mentum to angle with no jowl overhang Subhyoid depression (visually enhances the impression that the neck is thin and long) Visible thyroid cartilage bulge Visible anterior border of the sternocleidomastoid muscle, distinct in its entire course from the mastoid to the sternum (considered least important criterion) Cervicomental angle between 105 and 120° (or a 90-degree angle between the sternocleidomastoid and submental lines). An angle greater than 120° appears as a double chin or heavy neck. It has also been proposed that a chin projection of less than 3 mm posterior to the nose-lip-chin plane (Figure 1),10 and a well-defined inferior and posterior gonial angle11 contribute to an aesthetically balanced face.Figure 1.: The ideal neck and its measurements. NLCP, nose-lip-chin plane; SCM, sternocleidomastoid. From Rohrich RJ, et al. Plast Reconstr Surg 2006;118:1251–63 (reproduced with permission).10With aging, changes occur to the face, chin, and neck that result in a loss of the characteristic features of beauty. Fat in the face and neck is distributed among multiple discrete compartments. With aging, the compartments are affected in different ways, leading to loss of volume in some areas such as the midface and addition of volume in other areas such as the lower face, causing heavy jowls and an indistinct jawline and resulting overall in diminution of beauty features.12 Other factors that contribute to the aging face include atrophy of bone structure, ptosis of soft tissues, thinning of the dermis, and decreasing skin elasticity.13 In women, these changes in the middle and lower face lead to a squaring of the face, and loss of the oval shape and the symmetry of facial features; in men, aging often results in jowling and the obscuring of jawline definition. The goal of the emergent science and art of facial rejuvenation is restoration of youthfulness and beauty through subtle, natural changes that are within the context of the patient's age.1,14 Enhancing facial characteristics and symmetry using nonsurgical interventions has been shown to improve first impressions.1,15–17 However, a face that has an obvious cosmetically altered look is perceived negatively14; therefore, in aesthetic medicine, it is important to achieve gradual, subtle changes that result in the patient feeling more youthful and attractive. Although the chin and neck play an important role in facial beauty, treatment options for contouring and refining this area have been relatively limited. The standard of care for addressing the submental area is surgical intervention, including face/neck lift, direct fat excision, and liposuction.18 Although energy devices have been used for targeted fat reduction, they may not have undergone the rigorous testing required of drugs for approval or may not be optimized for the chin and neck. Thus, there is a need for a nonsurgical treatment option to improve the contour of the submentum through reduction of submental fat. With the recent approval of ATX-101 (deoxycholic acid injection; Kythera Biopharmaceuticals, Inc., Westlake Village, CA [an affiliate of Allergan plc, Dublin, Ireland]) in the United States (Kybella) and Canada (Belkyra), a new treatment option is available to provide gradual, customized reductions in submental fat to improve submental contour. The objective of the current supplement is to provide a comprehensive resource for physicians considering this novel treatment option. The next article of the supplement provides an overview of ATX-101, including its mechanism of action and the extensive clinical development program that supported its approval by the US Food and Drug Administration and Health Canada. The third and fourth articles are based on an innovative anatomy lab and injection practicum undertaken to explore the critical anatomy of the lower face, chin, and neck and inform proper injection technique for ATX-101. Because optimal patient experience is an important component of facial injectable treatments, the fifth article provides data from a clinical trial evaluating different approaches to managing patient comfort during ATX-101 treatment. Finally, the sixth article provides considerations to improve patient management with ATX-101 treatment based on the findings from this clinical trial, a review of the literature, and expert opinion.

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