Horizontal neck lines (“necklace lines”) are common by age 40 due to repetitive folding, collagen loss, and skin thinning. The most effective treatment depends on severity, but hyaluronic acid (HA) filler is generally the best single option for moderate, static lines. When injected superficially with a soft, low–G’ filler, it directly fills the crease and produces natural-looking improvement that can last up to a year. For milder lines, especially those that worsen with movement, microtoxin (intradermal botulinum toxin) can help. It relaxes superficial muscle activity and improves skin texture, though results are more subtle and typically last 3–4 months. It is often used as an adjunct rather than a standalone treatment. A multimodal approach often provides the best overall results. Combining HA filler (to restore volume), neuromodulator (to reduce dynamic creasing), and energy-based devices such as radiofrequency microneedling or ultrasound (to stimulate collagen and tighten skin) addresses multiple contributing factors at once. This is especially helpful when there is early skin laxity or crepey texture. Topical treatments like retinoids and sunscreen can support skin quality but will not significantly correct established lines. In most 40-year-old patients, optimal outcomes are achieved with HA filler as the foundation, with optional combination treatments tailored to skin quality and aesthetic goals.