Patients are looking for nonsurgical, minimally invasive options to address excess fat under the chin and neck. A submental fat pad, or a double chin, can occur due to a variety of factors, including genetics, lifestyle habits, stress, and hormone imbalances, or simply because of the aging process. This excess fat is not correlated with body mass and can, in some cases, be resistant to diet and exercise, which makes it particularly frustrating for patients.
Injection lipolysis with phosphatidylcholine has become a popular treatment option for submental fat in the last several years, but many patients experience pain, edema, erythema and a stinging sensation after injection. Although these side effects are temporary, they can take up to three days to disappear.
Enzymatic therapy can be a highly effective and safe alternative, as it allows practitioners to perform tissue remodeling with minimal downtime and negligeable adverse side effects. In this article, I will break down how to use enzymes to treat the submental fat pad and discuss the boundaries of this approach.
How Enzymes Work in the Double Chin
There are three recombinant enzymes that can be applied simultaneously to successfully reduce the fat in the submental region:
This is the most important enzyme we need to remodel subcutaneous tissue and decrease the double chin. Triglyceride is the specific substrate for this enzyme, so Lipase reduces fat by binding triglycerides that accumulate inside the adipocytes in the adipose tissue. After binding the corresponding triglyceride, it will be turned into one molecule of glycerol and three molecules of free fatty acids, which will enter into the blood stream to be taken by the tissues in order to obtain energy.
This enzyme does not cause tissue necrosis because it does not kill the fatty cells. While human lipase is regulated by hormones such as catecholamines or insulin, and its effect depends on these hormones, recombinant lipase is not sensitive to hormonal regulation, which makes it very effective at any time. It will not be inhibited by the action of insulin, no matter the amount of insulin and sugar in blood.
The submental fat pad is surrounded by the extracellular matrix where collagen fibers are located above adipocytes, which can make it more difficult for lipase to reach the site of action. In cases where we need to dissolve excess collagen to help reduce fat content, we use collagenase. We can feel secure using this enzyme to dissolve collagen because the collagen no longer provides structural scaffolding.
Removing these collagen fibers will also promote the activation and proliferation of fibroblasts, which will synthesize new collagen. These new, stronger collagen fibers will provide a tightening effect, renewing firmness and elasticity in the submental area.
Submental fat can be enhanced due to liquid retention in the extracellular matrix, making it more noticeable. We can solve this problem thanks to the action of hyaluronidase. This enzyme breaks down extracellular polysaccharides, which are responsible for water retention in the extracellular matrix. By breaking down these molecules, hyaluronidase releases the trapped liquid that has accumulated in the tissue.
When reducing fluid retention, this enzyme also facilitates the diffusion of the other enzymes through the extracellular matrix, helping them to reach their site of action.
Step 1: Reconstitute the serum containing the enzymes to a volume of 8 mL. Then, position and disinfect the patient.
Step 2: Draw a line between the masseteric muscles. From the midline, eight equal squares approximately 1 cm in size are marked as seen in Figure 1.
Step 3: With a 30G needle, inject 1 cc of serum into each square (0.5 cc should be injected in the deep subcutaneous plane and 0.5 cc in the intradermal plane).
We recommend at least two treatments with 15 days between sessions. A follow up at 30 days after the first treatment should be scheduled, in which the results should be discussed with the patient and a possible third treatment may be administered.
In our experience, patients saw results on the seventh day after the initial treatment, and most saw continued improvement until their next session. Some patients reported even greater improvement six weeks after their first treatment.
With the injection of this enzymatic cocktail, we find the swelling will last for a maximum of 48-hours after the injection. No complications such as nerve damage or skin ulceration occur due to the superficial nature of the injection.
About the Author
Jan Balczun, MD
Dr. Balczun is a German facial plastic surgeon with a practice in Bochum, Germany. He is internationally renowned for his expertise in non-invasive procedures around the head and neck region. He is a regular speaker at national and international conferences / workshops.