Is treating the neck alone with botulinum toxin (Botox) (onabotulinumtoxinA) effective for addressing platysmal banding?

Treating the Neck Alone with Botulinum Toxin for Platysmal Banding

Treating the neck alone with botulinum toxin (Botox) is highly effective for addressing platysmal banding and should be considered a first-line treatment option for this cosmetic concern. 1

Mechanism and Efficacy

Botulinum toxin works by causing transient non-destructive flaccid paralysis of the platysma muscles by inhibiting acetylcholine release from nerve terminals, thus reducing muscle contraction that causes visible banding. The FDA-approved onabotulinumtoxinA (BOTOX Cosmetic) has demonstrated significant efficacy in clinical trials:

• In two multicenter, randomized, double-blind, placebo-controlled trials, 31-32% of patients achieved a multi-component endpoint of minimal/mild severity with at least a 2-grade improvement from baseline at day 14, compared to only 0-2% with placebo 1
• Individual component success rates were even higher, with 42-45% of patients showing improvement on investigator assessment 1
• Patient satisfaction was high, with 56-62% of patients reporting being "satisfied" or "very satisfied" with treatment results at day 14 1

Dosing and Administration

The FDA-approved protocol for platysmal bands uses specific dosing based on severity:

• Doses of 26,31, or 36 units of onabotulinumtoxinA total, administered directly into the platysmal bands 1
• Typically 15-20 units per band is recommended 2
• Multiple injection points along each band ensure even distribution and optimal results

Duration of Effect

Treatment benefits for platysmal bands show:

• Rapid onset with effects visible within 3-8 days post-treatment 3
• Peak effect occurring at approximately 14 days 1
• Duration of effect lasting 3-5 months, with some patients maintaining improvement for up to 20-21 weeks 3

Safety Considerations and Potential Complications

While generally safe, there are important considerations:

• The most common adverse effect is bruising at injection sites 4
• The most serious potential complication is dysphagia (difficulty swallowing) due to diffusion of toxin to adjacent muscles 5
• Risk factors for complications include:
  • Improper injection technique
  • Excessive dosing
  • Possible intravascular injection
  • Individual patient sensitivity 5

Even with conservative doses (equivalent to 20 units of onabotulinumtoxinA), dysphagia has been reported, though this is rare 5

Patient Selection

Best candidates for treatment are those with:

• Visible platysmal bands at rest or with muscle contraction
• Type II or III neck aging (mild to moderate horizontal neck rhytids, mild to moderate platysma muscle flaccidity, and mild to moderate skin laxity) 6
• Realistic expectations about temporary nature of results

Patients with excessive skin laxity may have limited improvement with botulinum toxin alone and might benefit from combination treatments 4.

Treatment Limitations

Important limitations to discuss with patients:

• Results are temporary, lasting 3-5 months
• Treatment addresses muscle activity but not skin laxity
• No evidence of "lifting" of the lower face with platysmal band treatment alone 4
• Multiple treatments are required for maintenance

By following these guidelines and selecting appropriate patients, treating the neck alone with botulinum toxin provides a safe and effective non-surgical approach to addressing platysmal banding with high patient satisfaction rates.