top of page

Horizontal Neck Lines: Types, Causes, and Advanced Treatments

Horizontal neck lines, also known as necklace lines, are a common cosmetic concern. These linear depressions appear on the front of the neck and can be a source of frustration for patients. While often associated with aging, their development is more complex than just skin laxity.

Understanding the various factors that contribute to horizontal neck lines is crucial for offering effective treatment options. Age-related changes, sun damage, and genetics all play a role in the breakdown of collagen and elastin, leading to thinner skin and wrinkle formation. Repetitive neck movements, particularly looking down at devices like phones and tablets, can also contribute by shortening and folding the platysma muscle in the neck. Interestingly, research suggests a link between less subcutaneous fat in the neck and the development of horizontal neck wrinkles. Individuals with higher body fat percentages may have less prominent lines due to a plumper underlying tissue layer. In this blog, we will discuss the types, causes, and alternative of advancement treatments in considering the right treatment.


Horizontal neck lines, a prevalent aesthetic concern, transcend the realm of mere wrinkles. Their formation is a complex interplay between intrinsic and extrinsic factors, resulting in distinct presentations that demand a nuanced understanding for effective treatment. Here, we delve deeper into the scientific underpinnings of these lines, exploring potential classifications based on depth and contributing elements.

1.Depth as a Differentiator

While a formal classification system for horizontal neck lines is absent, stratifying them based on depth offers valuable insights for treatment strategies.

  • Fine Lines (Epidermal Involvement): These represent the initial phase of wrinkle formation, manifesting as superficial depressions primarily affecting the epidermis, the outermost layer of the skin. Intrinsically, chronological aging leads to a decline in collagen and elastin production, the structural pillars of youthful skin. Extrinsic factors, particularly chronic sun exposure and its associated photodamage, further exacerbate this decline, weakening the skin's matrix and promoting the formation of fine lines.

  • Deep Lines (Dermal Involvement): As the aging process continues, and environmental insults accumulate, the damage extends beyond the epidermis, reaching the dermis, the middle layer of the skin. Here, a loss of glycosaminoglycans (GAGs) and hyaluronic acid, key components of the dermal extracellular matrix (ECM), further compromises structural integrity. This progressive loss of support manifests as deeper, more pronounced horizontal lines.


While depth provides a valuable framework, a deeper understanding necessitates exploring the specific factors contributing to horizontal neck lines:

1. The Collagen and Elastin Conundrum

Chronological Decline and Gene Expression:  Fibroblasts, the resident cell population within the dermis, are responsible for collagen and elastin synthesis. However, chronological aging leads to a downregulation of genes associated with collagen (COL1A1, COL3A1) and elastin (ELN) expression. This decline in protein synthesis disrupts the structural integrity of the extracellular matrix (ECM), manifesting as a loss of skin firmness and the formation of wrinkles. Further research into the specific signaling pathways involved in age-related downregulation of these genes holds promise for the development of novel therapeutic strategies.

Matrix Metalloproteinases (MMPs) and the Dismantling Crew:  MMPs are a family of enzymes naturally produced by the body and play a physiological role in ECM remodeling. However, their activity can become dysregulated with aging, leading to excessive degradation of collagen and elastin. Specific MMP subtypes, such as MMP-1 and MMP-3, have been implicated in wrinkle formation. Understanding the mechanisms that control MMP activity and developing MMP inhibitors could be a potential avenue for therapeutic intervention.

2. Extrinsic Insults and Photoaging Pathways

Chronic exposure to UV radiation from sunlight disrupts the skin's delicate balance. UV photons directly damage collagen and elastin fibers, leading to their fragmentation and loss of function. Additionally, UV exposure triggers the generation of reactive oxygen species (ROS), which further contribute to cellular damage and ECM degradation through oxidative stress pathways. Exploring the role of specific ROS and their downstream signaling cascades can inform the development of cosmeceutical ingredients with antioxidant properties to mitigate photoaging.

Glycation, the non-enzymatic attachment of sugars to proteins, is a normal physiological process. However, excessive glycation can lead to the formation of AGEs, which accumulate in the ECM over time. AGEs stiffen collagen fibers and impair their functionality, further contributing to wrinkle formation. Delving deeper into the mechanisms by which AGEs exert their effects and exploring strategies to limit their formation or accumulation could be a promising avenue for preventing and treating horizontal neck lines.

3. Repetitive Strain and the Platysmal Paradox: Biomechanical Forces and Muscle Hypertrophy

The platysma muscle, a broad sheet in the neck, facilitates facial expressions like frowning and grimacing. However, repetitive downward pulling movements, often associated with "tech neck" from excessive phone use, can lead to biomechanical strain on the muscle. This chronic strain can induce hypertrophy (enlargement) of the platysma, and the resulting shortening and thickening of the muscle fibers manifests as deeper horizontal bands across the neck. Understanding the interplay between biomechanical forces, muscle activation patterns, and potential genetic predispositions to platysmal hypertrophy can inform the development of preventative strategies and targeted treatment approaches.

4. Subcutaneous Symphony: The Role of Fat Distribution and Adipogenesis

Recent research suggests a potential link between a deficiency in subcutaneous fat and the development of horizontal neck lines. This loss of underlying volume can contribute to the appearance of wrinkles with less defined edges, distinct from the sharper demarcation seen in purely collagen-loss-related lines. While the exact mechanisms are still being elucidated, potential factors include age-related decline in adipogenesis (fat cell formation) and hormonal changes that influence fat distribution. Investigating the role of specific adipocytokines (signaling molecules secreted by fat cells) and their impact on skin health could be a valuable area of exploration.

5. Genetic Predisposition: The Individual Equation and Polygenic Effects

Individual susceptibility to horizontal neck lines can be influenced by variations in specific genes. These Single Nucleotide Polymorphisms (SNPs) can affect collagen and elastin production, enzymatic activity related to ECM degradation, and the skin's response to environmental insults like UV radiation. While individual SNPs may have a small effect size, their cumulative impact (polygenic effect) can significantly influence a person's risk of developing wrinkles. Identifying relevant SNPs and understanding how they interact with environmental factors can pave the way for personalized preventive and therapeutic approaches.

Treatment Methods

Horizontal neck lines, a persistent aesthetic concern, necessitate a multifaceted treatment approach that tackles the underlying causes and promotes visible improvement. Here, we delve deeper into the scientific basis of various treatment modalities currently available to dermatologists, exploring their mechanisms of action and considerations for optimal use.

1.Topical Therapies

While topical treatments may not offer dramatic wrinkle reversal for deep lines, they play a valuable role in overall skin health and can be beneficial for early intervention or in conjunction with other modalities.

Retinoids: These vitamin A derivatives exert their effects by binding to specific receptors on fibroblasts, the workhorse cells of the dermis. This binding stimulates collagen production and enhances epidermal turnover, leading to a thicker dermis and improved skin texture. Retinoids may be particularly effective for fine lines by promoting the shedding of damaged outer layers of skin (stratum corneum) and reducing the impact of photodamage.

Peptides: Specific peptide sequences can act as signaling molecules, mimicking the effects of naturally occurring growth factors. These peptides can stimulate collagen synthesis and promote the repair of the extracellular matrix (ECM) by fibroblasts. While research is ongoing to define optimal formulations and delivery methods, topical peptides hold promise as a non-invasive approach for improving skin quality and potentially mitigating the formation of fine lines.

Growth Factors: Growth factors, such as platelet-derived growth factor (PDGF) and epidermal growth factor (EGF), play a crucial role in cellular proliferation and ECM production. While topical delivery has limitations due to the skin's barrier function, growth factors may be a consideration in combination with other modalities, particularly for deeper lines. Their potential benefit lies in stimulating the growth of new fibroblasts and promoting the production of collagen and other ECM components.

2. Injectable Fillers

For addressing established wrinkles and volume loss, injectable fillers offer a more targeted approach.

Hyaluronic Acid (HA) Fillers: These fillers are composed of HA, a naturally occurring sugar molecule that plays a key role in skin hydration and structure. HA fillers are injected directly into the dermis, where they bind water molecules, creating volume and smoothing wrinkles. The selection of the appropriate HA filler type (viscosity, particle size) depends on the depth and severity of the wrinkles. For instance, high-density fillers are better suited for deep lines, while softer fillers can provide a more natural-looking correction for fine lines.

3. Energy-Based Devices

While not a one-size-fits-all solution, energy-based devices offer additional options for addressing horizontal neck lines. Their efficacy depends on the specific technology employed and the severity of the wrinkles.

Radiofrequency (RF) Therapy: RF devices deliver controlled heat energy to the dermis. This heat triggers the denaturation of existing collagen fibers, stimulating the body to produce new, more organized collagen. This process can lead to skin tightening and a reduction in the appearance of wrinkles. However, RF therapy may not be effective for all types of horizontal neck lines, particularly deep ones.

Fractional Lasers: Ablative and non-ablative fractional lasers create microscopic columns of injury within the dermis. This controlled damage triggers a wound healing response, promoting collagen remodeling and skin tightening. While potentially effective for deeper lines, these procedures require careful technique and proper patient selection to minimize side effects like post-inflammatory hyperpigmentation.

4. PDO Threads

Horizontal neck lines (HNLs) pose a significant aesthetic concern, impacting individuals of varying ages. Polydioxanone (PDO) threads present a novel and scientifically validated approach for dermatologic surgeons, offering a minimally invasive solution to address HNLs. This approach goes beyond simple physical lifting and delves into the realm of cellular and molecular mechanisms.

The efficacy of PDO threads hinges on their ability to stimulate neocollagenesis, the de novo synthesis of collagen. PDO threads act as a biocompatible scaffold within the subcutaneous tissue. This scaffold triggers a cascade of cellular events, including the recruitment and activation of fibroblasts. Fibroblasts are the primary collagen-producing cells in the skin. PDO threads, particularly barbed varieties, induce the expression of transforming growth factor-β (TGF-β) by these fibroblasts. TGF-β is a potent signaling molecule that upregulates the production of type I and III collagen, the major structural components of the dermis. This neocollagenesis strengthens the extracellular matrix (ECM), leading to improved skin elasticity and a reduction in HNL visibility.

In conclusion, horizontal neck lines, more than just wrinkles, stem from a complex interplay of aging, sun damage, genetics, and even phone use. While topical treatments can help with early intervention, a multifaceted approach is key. This may involve injectable fillers for volume restoration, energy devices for skin tightening, or PDO Threads, all depending on the specific cause and wrinkle depth. Understanding these factors empowers both patients and dermatologists to achieve smoother and more youthful neck appearances.


Treatment of Horizontal Neck Wrinkles with Hyaluronic Acid Filler: A Retrospective Case Series (2019)

Efficacy and safety of hyaluronic acid filler on the treatment of horizontal neck lines (2022)

Horizontal necklines correction with absorbable braided polydioxanone threads: Case series (2024)

Long-Term Efficacy of Anchored Barbed Sutures in the Face and Neck (2008)


Discover the Science behind Minimally-Invasive Facial Rejuvenation & Lifting

in our upcoming Mini Fellowship and Master Classes happening globally:

IFAAS Mini Visiting Fellowship

Korean Advanced Non-Surgical Face Lifting

April 13-14, 2024 - Vancouver, Canada - [Register Now]


June 23-24, 2024 - Sydney, Australia  - [Register Now] 


More Upcoming Global Events


bottom of page