Botulinum Toxin for the Neck

What Is Botulinum Toxin for the Neck?

Botulinum toxin for the neck is the injection of botulinum toxin type A into the platysma muscle in the neck. The aim is to temporarily reduce the vertical bands that appear at the front of the neck when the muscle contracts, and the muscle’s downward pull on the jawline. The popular name for these injections is in fact a product name that has passed into everyday language; several products contain the same active ingredient, botulinum toxin.

The platysma is a thin muscle that lies just under the skin. According to a review of injection anatomy, it covers the whole of the neck and the lower part of the face; it is also the main target of botulinum toxin treatments for platysma bands and for lifting the lower face. In other words, botulinum toxin for the neck is injected into a muscle that is not limited to the neck but is connected to the lower edge of the face.

The medical name for the appearance this muscle causes in this area is platysma prominence. According to a definition based on scientific publications and expert opinion, it has two main features: a less defined jawline, and vertical bands on one or both sides of the neck, running along the front and back edges of the muscle. A meta-analysis that pooled the results of randomised trials also describes platysma prominence as a common age-related aesthetic concern.

You can read about how botulinum toxin works in general, how its effect develops and fades, and its other uses in the face on the general botulinum toxin page.

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Why Do Platysma Bands Form?

Platysma bands are the edges of the muscle that stand out as vertical strips at the front of the neck when the muscle contracts. These bands come from the muscle itself, not from the skin; this is why a treatment that reduces muscle movement can target them.

In a study that used ultrasound to examine why the bands form at the edge of the muscle, there was no significant difference in thickness between the measured points of the muscle at rest. During contraction, however, the front and back edges of the muscle became thicker than its middle, and the muscle bulged outwards. The researchers concluded that the bands are linked to this thickening. Even so, exactly how the bands form has not yet been clearly established.

The nerves that supply the muscle also help to explain the picture. An anatomical study on cadavers found that the neck (cervical) branch of the facial nerve spreads across the muscle as a whole, while the jawline (marginal mandibular) branch gives extra supply to the uppermost part of the muscle; other nerves were also traced in the lower half of the muscle. The researchers stress that this distribution should be taken into account when injections are planned.

In practice, the distinction is this: if a band appears only when the muscle contracts, the picture is mainly muscle-related. According to a review of non-surgical neck rejuvenation methods, people with little skin laxity whose bands become prominent with muscle movement may benefit from botulinum toxin. If a band is also visible at rest and is accompanied by skin laxity, relaxing the muscle alone may not meet your expectations.

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What Do Randomised Trials Show?

Vertical neck bands are the main feature for which botulinum toxin has been studied in this area in randomised, placebo-controlled trials. In these trials, participants are assigned to groups at random; one group receives the medicine and the other an inactive injection (placebo). There are phase 2 and phase 3 trials in adults with moderate or severe platysma prominence, and two meta-analyses that combined their results.

In one of the phase 3 trials, participants were followed for 120 days after a single treatment. On day 14, the proportion who improved by at least two grades on both the investigator’s and their own assessment, and reached a mild or minimal level, was 32.3% in the treatment group and 1.9% in the placebo group. In the other phase 3 trial, in a group of participants who were psychosocially affected, improvement of at least one grade on the investigator’s assessment was found in 76.7% of the treatment group and 21.2% of the placebo group. Responder rates stayed above placebo up to day 120, but gradually declined over time.

A meta-analysis that combined data from 912 participants in three randomised trials found that treatment significantly increased the chance of improving by at least one grade and by at least two grades compared with placebo; the frequency of adverse effects was similar to placebo. A second meta-analysis of the same trials also found significant improvement compared with placebo on days 14, 60 and 120; there was no significant difference between the groups in safety outcomes, including difficulty swallowing or speaking.

When reading these results, you need to know some of their limitations. The trials were carried out with a single product and a specific dosing schedule; the results cannot be taken as directly applying to other products. In the phase 2 trial, 95.1% of participants were women and 93.9% were white. One of the phase 3 trials also names the fact that it assessed only a single treatment as one of its own limitations. These figures belong to the groups that took part in the trials; they cannot be used to predict your result.

Licensing and approval status varies by country and by product. A product being approved for this use in another country does not show its licensing status in Türkiye or whether the treatment is suitable for you. The product type to be used and its licensing status are discussed at your consultation.

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How Long Does the Effect Last, and What Happens With Repeat Treatments?

For neck bands, the effect is not permanent. In randomised trials, improvement was assessed on day 14 and followed for up to 120 days; during this time, responder rates stayed above placebo but gradually declined.

A systematic review (a review that searches for and assesses the studies on a topic using set rules) of botulinum toxin for lifting the lower face and neck assessed data from 11 studies; the effect reported by patients lasted up to 12 weeks. The researchers stress that consistent, objective measures need to be developed to assess the lifting effect accurately.

In an open-label phase 3 trial of repeat treatments (a trial in which everyone knows which medicine is given), participants received up to four treatments, at least three months apart. All treatment-related adverse effects were reported as mild, and they did not tend to increase as treatment was repeated. On day 14, the rate of improvement by at least one grade on the doctor’s assessment was reported as between 83.6% and 98.0%, depending on the treatment cycle. This trial was also carried out with a single product.

Antibody formation and non-response with repeated botulinum toxin treatments are covered on the general botulinum toxin page. How often and at what intervals your neck should be treated is a decision your doctor makes for you individually, and it is discussed at your consultation.

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Horizontal Neck Lines

For horizontal neck lines, the evidence for botulinum toxin is clearly weaker than for vertical bands. These lines run across the front of the neck and are a different finding from the vertical bands that appear when the muscle contracts.

A systematic review of botulinum toxin for neck wrinkles describes these wrinkles as a sign of ageing of the neck skin. The review could find only five studies with a total of 112 women; in three of these the toxin was used on its own, and in two it was combined with other methods. No serious or permanent side effects were reported, but the review concluded that the available research could not strongly prove an effect.

A prospective observational study that followed 20 women reported significant improvement on doctors’ assessments, but patients’ rates of improvement and satisfaction did not exceed 50%; adverse effects were mild and temporary. A randomised trial compared a combination of non-cross-linked hyaluronic acid and mesotherapy with botulinum toxin. The combined treatment gave greater improvement in line grade at all follow-up visits; however, pain, redness, swelling and bruising were more frequent and lasted longer in this group. This trial also stresses that botulinum toxin has limited effectiveness for horizontal neck lines.

A meta-analysis of hyaluronic acid fillers for horizontal neck lines reported significant improvement in wrinkle grade and on the global aesthetic improvement scale across 11 studies; this analysis was rated as level IV evidence. A source on neck anatomy mentions using the toxin to prevent horizontal lines from getting worse with age. In short, because the question with horizontal lines is about skin ageing, other methods are also considered.

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Jawline and Lower Face

The platysma extends up to the lower part of the face, and when it contracts it can make the jawline look less defined. This is why studies look at neck treatments together with the jawline. In one of the phase 3 trials on platysma prominence, jawline definition was also among the outcomes assessed, and participants reported improvement in how defined they felt their jawline was.

Treatment of the platysma bands and along the jawline is known as the ‘Nefertiti lift’. In a clinical study of 30 patients, platysma bands improved significantly both at rest and during contraction. Other features of the lower face, such as jowls (sagging along the jawline), the corners of the mouth and neck volume, showed a trend towards improvement, but the difference did not reach statistical significance. The study was rated as level IV evidence.

A systematic review of its use for lifting the lower face and neck reported that injections into the skin (intradermal) or under the skin (subcutaneous) along the jawline showed a lifting effect; however, consistent measures need to be developed so that this effect can be measured objectively. An expert consensus on the lower-face muscles also lists bands, reshaping of the jawline and skin texture among the uses of platysma treatments. You can find details of treatment for the jawline on the Jawline and Neck (Nefertiti Lift) page.

RELATEDBotulinum Toxin for the Jawline and Neck (Nefertiti Lift)

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Limits of This Treatment

Botulinum toxin for the neck is a treatment aimed at muscle movement; it does not lift loose, sagging skin, does not remove excess skin, and does not change the fat under the chin or deeper structures. Because neck ageing does not have a single cause, no single treatment can address the whole picture.

According to a review of this area, ageing under the chin and in the neck is caused by several factors together: loosening of the platysma, redistribution of fat, bone remodelling and changes in skin quality. A proposed classification of neck ageing also treats skin, fat and muscle as three separate axes: it places botulinum toxin as the option for excess muscle activity, and collagen stimulators as the option for skin laxity.

Research has also looked at who responds more clearly. It has been reported that people with little skin laxity whose bands become prominent with muscle movement may benefit from botulinum toxin. The 30-patient clinical study also reported that the treatment was useful particularly in younger patients with an overactive platysma muscle and preserved skin elasticity, and that the greatest improvement was seen in people whose features were milder at the start.

With marked skin laxity and excess skin, other approaches are considered: the classification above matches skin laxity with collagen stimulators; the thread lift method, which aims to reposition the tissue, is described on the Neck Thread Lift page; and in advanced cases surgery is discussed. A large systematic review of neck lift operations (57 studies, 8,648 patients) reported that deep-plane techniques reach deeper structures, but have a higher rate of nerve paralysis than a classic neck lift, and therefore patients need to be given detailed information.

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Neck Anatomy and Safety

The neck lies right next to the structures responsible for swallowing and voice production. For this reason, the key safety question with botulinum toxin in this area is whether the effect of the toxin spreads beyond the target muscle.

Injections given without knowledge of the anatomy of the platysma muscle and the properties of the toxin can cause side effects such as difficulty swallowing (dysphagia), voice changes and weakness of the neck muscles. To reduce this risk, injection points based on the outline of the jawbone have been proposed, with the aim of keeping the dose and the number of injection points to a minimum.

According to research on toxin spread, most local and distant complications are attributed to unwanted spread of the toxin’s effect to nearby and distant muscles; the injected volume and the dilution ratio can affect this spread. An expert consensus on the lower-face muscles also states that the risk of side effects is higher because the muscles in this area have important functions, and stresses the need for standard techniques to reduce functional complications.

Nerve distribution also varies from person to person. In a cadaver study, a connecting branch between the neck (cervical) branch of the facial nerve and the transverse cervical nerve was found in 30% of cases, and between the cervical branch and the great auricular nerve in 20%. The researchers state that injections should take into account not only how the cervical branch spreads across the muscle, but also the other nerves that reach the middle and lower parts of the muscle.

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Known Risks

Botulinum toxin for the neck is a medical procedure using a prescription-only medicine, and it has side effects. Most of those reported in controlled trials are mild and temporary; however, difficulty swallowing (dysphagia), voice changes and weakness of the neck muscles are neck-specific risks that you also need to know about.

The findings from controlled trials are as follows. In the phase 2 dose trial, most treatment-related adverse effects were linked to the procedure itself, temporary and mild; the most common medicine-related adverse effect was neck muscle weakness, reported in the high-dose group. In one of the phase 3 trials, the frequency of adverse effects was similar to placebo, and no difficulty swallowing or muscle weakness was reported. In the repeat-treatment trial, six events of special interest occurred in four participants: four of difficulty swallowing and two of facial muscle weakness. All of them were mild, no sign of the toxin spreading to distant areas was found, and almost all had resolved by the end of the trial.

There are also reports from outside controlled trials. A case report has been published of a patient who developed difficulty swallowing after treatment of platysma bands. A review of rare and serious complications lists neck weakness, hoarseness and difficulty swallowing in connection with botulinum toxin. Another review of serious and long-term side effects reported problems such as difficulty swallowing, breathing difficulties and widespread muscle weakness; these are more common when the toxin is used to treat medical conditions, but can also occur after cosmetic use.

These figures and cases come from studies in other people; they cannot be used to calculate your personal risk. What to do if you notice any change in swallowing, speaking or neck movement after treatment is set by your doctor’s own protocol and explained to you at your consultation. Special situations such as neuromuscular disorders, pregnancy and breastfeeding are covered on the general botulinum toxin page.

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