Journal of Cosmetic and Laser Therapy, 2014; 16: 284–289

ORIGINAL ARTICLE

Laser assisted lipolysis for neck and submental remodeling in Rohrich

type I to III aging neck: A prospective study in 30 patients

FRANCK MARIE LECLÈRE1,2,5,6*, JAVIER MORENO-MORAGA3*, JUSTO M. ALCOLEA4,

VINCENT CASOLI2, SERGE R. MORDON5, PETER M. VOGT6 & MARIO A. TRELLES4
1Department Plastic and Reconstructive Surgery, Gustave Roussy Cancer Campus Grand Paris,
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2Department Plastic-, Hand-, Burn-, and Transsexual Surgery, CHU University of Bordeaux, Bordeaux, France,
3Instituto Médico Láser, Madrid, Spain, 4Instituto Médico Vilafortuny, Fundacion Antoni de Gimbernat, Cambrils,

Tarragona, Spain, 5INSERM U703, Lille University, Lille, France, and 6Department Plastic and Reconstructive
Surgery, MHH Hannover Medical School, Hannover, Germany

Abstract
Background: Since the first studies by Apfelberg in 1994 and the mathematical model by Mordon in 2004, laser lipolysis
(LAL) has been on the rise. Laser lipolysis has the advantages of reduced operator fatigue, excellent patient tolerance, quick
recovery time, as well as the additional benefit of dermal tightening. This article reports our experience with laser-assisted
lipolysis (LAL) in submental and neck remodelling. Methods: Between June 2010 and January 2013, a prospective study
For personal use only.

was performed on 30 patients treated for Rohrich type I to III aging neck, with LAL. The laser used in this study was a
980 nm diode laser (Quanta system, spa model D-plus, Solbate Olona (VA), Italy). Laser energy was transmitted through
a 600 μm optical fiber and delivered in a continuous mode 15 W power. Previous mathematical modelling suggested that
0.1 kJ was required in order to destroy 1 ml of fat. Patients were asked to fill out a satisfaction questionnaire. The cervi-
comental angle was measured 6 months post-operatively and compared with the preoperative values. Results: Other than
three patients who developed mild hyperpigmentation that disappeared after 4 months, there were no complications in the
series. Pain during the anaesthesia and discomfort after the procedure were minimal. The time taken to return to normal
activities was 3.2 ⫾ 1 days. All patients would strongly recommend this treatment. Overall satisfaction was high with both
patients and investigators and was validated by decrease in cervicomental angle demonstrating a systematic decrease in fat
thickness and improved skin tightening. Conclusion: LAL is a safe and reproducible technique for remodeling in Rohrich
type I to III aging neck. The procedure allows for a reduction in the amount of adipose deposits while providing concurrent
skin contraction.

Key Words: aging neck, laser, laser lipolysis, LAL, submental, submental remodeling, tissue remodeling

Introduction However, these techniques have the following limita-

Signs of an aging neck include decreased skin quality
and wrinkling because of photodamage, skin laxity,
and submental and subplatysmal fat accumulation,
all of which lead to an increase of the cervicomental
angle which exceeds 120° and softening of the
mandibular contour (1,2).
Conventional surgical approach and tumescent
liposuction continues to be the most common
cosmetic procedures for submental and neck remod-
eling depending on the level of senescence (3).
tions: increased blood loss, ecchymoses, long recov-
ery times, increased postoperative discomfort,
potential for pulmonary emboli, and seromas. The
search for and development of new techniques such
as minimally invasive skin tightening (MIST) (4) and
laser assisted lipolysis (LAL) (5) have been on the
rise over the past decades.
Since 2004, and using our mathematical model,
we have been working towards developing a safe
technique for LAL (6). Based on the literature and
our previous observations (7–11), laser-assisted

*Franck Marie Leclère, MD, PhD and Javier Moreno-Moraga, MD contributed equally to this article.
Correspondence: Department Plastic-, Hand-, Burn-, and Transsexual Surgery, Centre François-Xavier-Michelet, groupe hospitalier Pellegrin, CHU University
of Bordeaux place Amélie-Raba-Léon, 33076 Bordeaux cedex, France. E-mail: franckleclere@yahoo.fr; franck.leclere@inserm.fr

(Received 25 March 2014 ; accepted 25 May 2014 )

ISSN 1476-4172 print/ISSN 1476-4180 online © 2014 Informa UK, Ltd.
DOI: 10.3109/14764172.2014.946053
 LAL in Rohrich type I to III aging neck 285

lipolysis is a reliable technique because of the follow- Table I. Patients‘demographics.

ing reasons: (1) the effect of lipolysis improves and Fitzpatrick Rohrich Submental
facilitates the removal of adipose tissue; by liquefying N Age BMI skin type grade angle (°)
the adipose tissue. (2) The disruption and coagula-
1 48 28.5 III III 165
tion of collagen may lead to the creation of a new, 2 39 26.7 III II 153
thicker and more organized reticular dermis; the 3 51 25.2 III III 161
clinical end results being tightened skin and reduced 4 38 29.8 IV III 162
laxity. (3) Due to the small cannula size, mechanical 5 41 27.1 III II 149
destruction is kept to a minimum, resulting in faster 6 49 28.4 II II 152
7 66 27.7 IV III 146
recovery times and a lower incidence of ecchymoses. 8 52 29.9 III II 158
(4) Coagulation of small vessels reduces procedural 9 47 28.2 II II 147
trauma. (5) The easy penetration of the laser fibre 10 46 25.7 II II 151
into the fibrous tissue makes it easier to reach all of 11 37 27.9 III I 139
the areas with the help of the external hand, contrib- 12 42 32.7 IV III 165
13 44 27.7 III II 159
uting to high patient satisfaction. 14 39 29.2 II II 148
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In this article, we present a prospective series of 15 43 33.6 III III 169

submental and neck remodelling with laser-assisted 16 52 27.8 II II 154
lipolysis (LAL) and discuss its numerous advantages. 17 54 31.6 II III 163
We reviewed the skin contraction, the complications, 18 39 30.3 III II 152
19 48 27.5 III II 146
and the patient satisfaction. Our results are discussed 20 51 35.8 III III 164
and compared to the current literature. 21 48 32.9 II II 144
22 37 32.1 III II 145
23 50 26.3 IV I 138
Material and methods 24 36 28.8 III II 149
25 38 29.6 IV II 156
Patients 26 44 27.1 III II 147
For personal use only.

27 49 24.2 II I 134
The protocol of this clinical study was reviewed and 28 51 27.3 III II 151
approved by our local ethics committee. Thirty 29 53 26.4 III II 148
patients who were dissatisfied with the aspect of their 30 40 33.8 II II 162
neck were recruited for our study. The exclusion cri-
teria were the following: Rohrich type IV aging neck,
pregnancy, history of coagulation disorders or anti-
coagulants, history of allergy to the active ingredients Industry Co. Ltd, China). Total energy delivered to
or excipients of the anaesthetics used and history of the submental area treated varied from 10 to 14 kJ.
sensitivity to laser treatment or IPL. The patients
were phototype I to IV and their mean age was Surgical technique
45.73 ⫾ 6.0 years (range 37–66 years) (Table I). The
patients’ mean body mass index (BMI) was 29.0 ⫾ 2.8 In all patients, tumescent anaesthesia was used (Klein
kg/m² (range 24.2–35.8 kg/m²). Patients were classi- formula, 0.1% lidocaine and 1:1,000,000 epineph-
fied according to the Rohrich classification (14): rine) (12). Infiltration ranged from 200 to 300 ml.
Type I: No skin laxity, excellent skin tone, and lip- All patients received light sedation with midazolam,
odystrophy; Type II: mild skin laxity with or without controlled by the anaesthesiologist. Total energy
narrow medial platysmal bands (⬍ 2 cm); Type III: was applied by a crossed-fanning movement from
moderate skin laxity with or without wide platysmal various points in the deep plane. All patients received
bands (⬎ 2 cm); Type IV: moderate-severe skin laxity the global energy previously calculated with our
and significant lipodystrophy (Table II). mathematical model. Afterwards, a 2-mm diameter
cannula using an aspiration device at 1 bar negative
pressure was used (Lipo-MR, Ordisi SA, Barcelona).
Laser and dosimetry
The laser used in this study was a 980 nm diode laser
(Quanta system, spa model D-plus, Solbate Olona Table II. Rohrich‘s classification.
(VA), Italy). Laser energy was transmitted through a Grade Score
600 μm optical fiber and delivered in a continuous
I No skin laxity, excellent skin tone, and lipodystrophy
mode 15 W power. Previous mathematical modeling II Mild skin laxity with or without narrow medial
suggested that 0.1 kJ was required in order to destroy platysmal bands (⬍ 2 cm)
1 ml of fat. Our parameters were sufficient to achieve III Moderate skin laxity with or without wide platysmal
42°C when temperature was externally measured in bands (⬎ 2 cm)
the treatment area using an infrared thermometer IV Moderate-severe skin laxity and significant
lipodystrophy
(CEM DT-880B, Shenzhen Everbest Machinery
 286 F. M. Leclère et al.

Additional treatment such as lymphatic drainage, Table IV. Questionnaire used for our study.
endermology or radiofrequency was not performed. TOLERANCE
A compressive garment (VOE, S.A. Barcelona, Spain)
was prescribed to be used at all times for 15 days to 1. Did you experience pain during anesthesia?
NO 0
keep the lax skin attached to the submental plane. YES Slight 1
After this time patients were recommended to use Moderate 2
the garment for a further 30 days only at night. Severe 3
Very severe 4
2. Did you feel discomfort after the procedure?
Objective assessment NO 0
YES Slight 1
For each follow-up, complications were carefully Moderate 2
recorded and special attention was paid to burns, Severe 3
persistent edema, pain and hyperpigmentation. Very severe 4
Fever, seromas, severe hematomas or prolonged 3. Has the procedure interfered with your daily activities?
NO 0
alterations in sensitivity were also carefully evaluated. YES Slight 1
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Assessment of skin aspects was performed 6 months Moderate 2

postoperatively using the following criteria: tight- Severe 3
ening, firmness, and regularity (Table III). The Very severe 4
cervicomental angle was measured preoperatively EFFICACY
a) Has the treatment fulfilled your expectations?
and at 6-months follow-up, using a goniometer. Percentage 90–100% 1
Maximum care was taken during measurements to 70–90% 2
ensure that the patient’s head was held in the same 40–70% 3
position, to allow comparative evaluation of angle 10–40% 4
degree change. b) Would you recommend this treatment to others?
YES 1
NO 2
For personal use only.

Subjective assessment OVERALL OPINION OF THE INVESTIGATOR

Efficacy Very Good 1
The patients were asked to rate their level of discom- Good 2
fort during the anaesthesia and after the procedure Fair 3
No change 4
in a questionnaire (Table IV) (from 0 to 4) (0: no OVERALL OPINION OF THE PATIENT
pain/discomfort, 1: slight pain/discomfort, 2: moder- Efficacy Very Good 1
ate pain/discomfort, 3: severe pain/discomfort, 4: Good 2
very severe pain/discomfort) and their inability to do Fair 3
their daily activities (0: nil, 1: 1 day, 2: 2 days, 3: 3 No change 4
days, 4: more than 3 days). Patients were also asked
to rate their improvement 6 months postoperatively
(excellent, good, regular, poor). Moreover, they were
Student’s t- test (two samples) was used to calculate
also asked to score it (from 0% to 100%) on a visual
the p values, and p ⬍ 0.05 was considered to be
scale (expectations met: 4: 90–100%; 3: 70–89%; 2:
statistically significant.
40–69%; 1: 1–39%). Patients were asked whether
they would recommend the procedures to others.
Finally, the overall opinion of both the investigators
and patients was recorded. Results
Complications
Statistics Three patients were classified Rohrich Grade I,
Statistical analysis was performed using SPSS 19 patients were classified Rohrich Grade II and
program (SPSS 22.0). Data are presented as 8 patients were classified Rohrich Grade III. Only
mean ⫾ standard error of the mean. Where applicable, two patients Rohrich II and one patient Rohrich
III had mild hyperpigmentation that resolved in
4 months, even though neither of them initially had
Table III. Evaluation of the skin properties after LAL. ecchymosis or significant hematomas.
Skin Evaluation Score

Tightening 1 (good skin recovery ⬎ 80%) Subjective assessment

0 (good skin recovery ⬎ 80%)
Firmness 1 (smooth skin ⬎ 80%) Mean pain during the anaesthesia and mean discom-
0 (smooth skin ⬎ 80%) fort post procedure were, respectively, 0.3 ⫾ 0.6 and
Regularity 1 (absence of irregularities)
0.3 ⫾ 0.6. The time taken to return to normal activi-
0 (irregularities)
ties was 3.2 ⫾ 1 days. Mean subjective improvement
 LAL in Rohrich type I to III aging neck 287

was 1.4 ⫾ 0.6. All the operated patients would

strongly recommend this treatment. Overall mean
opinion of the treatment was similar for both the
patients and the investigators, that is, 1.3 ⫾ 0.5, and
1.3 ⫾ 0.6 respectively (Table IV).

Objective assessment
Mean skin tightening, firmness and regularity were,
respectively, 0.86, 0.78 and 0.96. The average cervi-
comental angle decreased from 152.6 ⫾ 5.9 to
123.6 ⫾ 8.8 degrees (p ⬍ 0.01) (Figures 1–2). This
demonstrated a systematic decrease in fat thickness Figure 2. A 66 year old patient (patient 7 of the series) before (A)
and improved skin tightening (Table V). and after (B) LAL for submental and neck remodeling.
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Discussion submental or neck fat excess. In 2012, Alexiades-

In this study, 30 patients who underwent LAL for
Rohrich type I to III aging neck were prospectively
assessed. Other than three patients who developed
mild hyperpigmentation that disappeared after 4
months, there were no complications in the series.
Pain during the anaesthesia and discomfort after the
procedure were minimal.All patients would strongly
For personal use only.
Armenakas proposed to use a combination of LAL
and MIST for neck rejuvenation (4). The combina-
tion temperature-controlled LAL-MIST was able to
treat excess fat and skin laxity of the submentum and
neck with excellent safety and efficacy for each grade
of neck senescence. Indeed, in the present study, we
could underline that LAL alone was able to provide
excellent results in terms of reduction in excess fat

recommend this treatment. Overall satisfaction was and skin tightening. Our results confirm the previous
high in both the patients and the investigators and studies from Goldman (5). Moreover, by using the
was validated by a decrease in the cervicomental
angle demonstrating a systematic decrease in fat
thickness and improved skin tightening. Table V. Submental angle before and 6 months after LAL.
Conventional surgical approach, tumescent lipo- Submental angle (°)
suction, and minimally invasive skin tightening have
been used alone or in combination to treat excess fat Before After Difference (°)
and skin laxity for submental and neck remodeling. 165 126 39
According to the literature, liposuction effectively 153 121 32
161 128 33
addresses excess fat and, and in Rohrich Grade I
162 131 41
patients, also resulted in excellent recontouring (3); 149 122 27
but in higher grades of neck senescence (Grades II 152 119 33
to IV), the residual skin laxity limits patient satisfac- 146 118 28
tion (13–15). MIST has been reported for neck 158 129 29
147 116 31
rejuvenation (16). However, it failed to address the
151 125 26
139 117 22
165 134 41
159 127 32
148 126 22
169 136 33
154 124 30
163 131 32
152 123 29
146 115 31
164 128 36
144 115 29
145 120 25
138 117 21
149 124 25
156 126 30
147 121 26
134 112 22
151 123 28
148 127 21
Figure 1. A 54 year old patient (patient 17 of the series) before 162 127 35
(A) and after (B) LAL for submental and neck remodeling.
 288 F. M. Leclère et al.
classification of Rohrich, we could establish that
LAL was able to treat Grade I to III with excellent
results. This was not the case in the study of
Noodleman and Harris, in which LAL failed to
address the residual skin laxity of the neck adequately
(17). We raise the hypothesis that the total laser
energy was probably underdosed in this study.
Indeed, the efficacy of laser lipolysis is deter-
mined by the type of wavelength and energy
delivered on tissue. Different wavelengths including
924, 968, 980, 1064, 1319, 1320, 1344, 1470 and
1440 nm have been selected for laser lipolysis in an
attempt to specifically target fat, collagen (water),
and blood vessels (18). According to the theory of
selective photothermolysis, these chromophores will
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preferentially absorb laser energy on the basis of their
absorption coefficients at specific wavelengths. As
demonstrated by the numerous wavelengths used for
laser lipolysis, it seems that the laser wavelength is
not a critical variable but, instead, laser intensity and
total laser energy dose are. Photoacoustic and pho-
tomechanical effects, together with photothermal
effects, are additional theorized mechanisms of action
in laser lipolysis. According to our experience with
several clinical trials and histological examinations,
heat is the primary stimulant for lipolytic and skin
For personal use only.
tightening effects. Our mathematical analysis six and
additional thermoregulatory studies (19,20) have
demonstrated that an internal temperature between
48 and 50°C must be reached for collagen denatur-
ization and subsequent skin tightening. External skin
temperatures between 38 and 41°C were identified
as safe and effective.
When the optimal temperature is reached, LAL
causes disruption of adipocyte membranes, coagula-
tion of blood and lymphatic vessels, and reorganiza-
tion of collagen (18). As a consequence, laser
lipolysis features reduced down time, as well as the
benefit of dermal tightening. The thermal action of
the beam makes the movement of the cannula easier
with less effort and fatigue for the surgeon. The treat-
ment of areas where fat removal is difficult, as in the
present studies, is facilitated by the small diameter
of the microcannula containing the laser fiber. The
excellent tolerance and high patient satisfaction are
confirmed in this study.
Despite the large number of patients and the
relatively long period covered in this study, method-
ological limitations remain. Firstly, this study was
limited by its nature as a non- controlled analysis.
Secondly, the study was limited to samples of the
Rohrich Grade I to Grade III aging neck. In case of
Grade IV, the results might have been different due
to the wide platysmal bands and extreme skin laxity.
In this context, we should mention that another
study is now being performed to maximise the out-
comes in Grade IV patients. Moreover, the proce-
dures were performed by surgeons who are experts
in LAL. The results might have been different with
surgeons at the beginning of the LAL learning curve.
Finally, the decrease in fat was measured indirectly
with the use of the cervicomental angle.
Despite all these limitations, one could question
why the use of LAL has taken so long to develop in
Europe (18). Besides the risk of burns claimed by
some surgeons, two aspects explain the limited global
development of LAL. The price of the equipment can
be initially prohibitive. The affordability of new
instruments, their rapid pay back, and the aforemen-
tioned benefits should contribute to a wider use of
this powerful tool. Some authors have previously
highlighted the long learning curve of the procedure.
However, two points will greatly help the beginner.
On the first hand, the new technologies that can help
to determine the required dosimetry are on the rise
and will help the young surgeons to reach the thresh-
old level of energy while avoiding the risk of thermal
damage: Cynosure has developed the SmartSense™
delivery system. This system contains an accelerom-
eter inserted into the intelligent handpiece. The
laser power is automatically adjusted by taking into
account the setting (high, medium or low) and
the motion of the cannula. Similarly, Osyris has
developed the LipoControl™ system. This system
integrates a magnetic tracking system to determine
the position of magnetic sensors in the cannula.
Owing to the tracking system, an automatic adjust-
ment of laser power is performed to compensate for
cannula movement. Consequently, the laser power
varies in step with the speed of the cannula so as to
continually deliver the optimal energy.
On the other hand, there is a high interest in
improving the teaching of laser techniques. In Europe,
with the development of the European laser diploma,
it is now possible to rapidly acquire experience and
discuss problems with experienced surgeons in laser
technologies.
Conclusion
LAL is a safe and reproducible technique for
remodeling in Rohrich type I to III aging neck. The
procedure allows for a reduction in the amount of
adipose deposits while providing concurrent skin
contraction.
Declaration of interest: The authors report no
declarations of interest. The authors alone are respon-
sible for the content and writing of the paper.
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