BACKGROUND: Since the first studies by Apfelberg in 1994 and the mathematical model of Mordon introduced in 2004, laser-assisted lipolysis (LAL) has been on the rise. In a previous study, we presented our results in patients treated with LAL for Rohrich type I to III aging neck. The average cervicomental angle decreased from 152.6 +/- 5.9 to 123.6 +/- 8.8 degrees after LAL. This demonstrated a systematic decrease in fat thickness, and improved skin tightening. OBJECTIVE: This new protocol focuses solely on LAL in the Rohrich type IV aging neck. METHODS: Between June 2012 and February 2013, a prospective study was performed on 10 patients treated with LAL for Rohrich type IV aging neck. The laser used in this study was a 1470 nm diode laser (Alma Lasers, Caesarea, Israel). Laser energy was transmitted through a 600 mum optical fiber and delivered in a continuous mode, at 15 W power. Previous mathematical modeling 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 cervicomental angle was measured 6 months postoperatively, and compared with the preoperative values. RESULTS: No seromas were observed, but prolonged edema was observed in two patients. Pain during anesthesia and discomfort after the procedure were minimal. The average cervicomental angle decreased from 191.5 +/- 5.7 to 164.9 +/- 14.2 degrees (p < 0.01). This demonstrated a systematic decrease in fat thickness and improved skin tightening. Even though the cervicomental angle was higher than 140 degrees in each case, the investigators, in agreement with the patients, decided to perform a complementary surgery with platysma muscle advancement and plication six months after LAL, in only two of the ten patients. This complementary surgery led to a mean cervicomental angle of 140.2 +/- 11.4, and fair satisfaction of both patients and investigators. CONCLUSION: LAL alone appears insufficient for complete remodeling in Rohrich type IV aging neck. While LAL alone is sufficient for Grade I to III, a complementary surgery must be added for Grade IV.