What is the best treatment for sagging neck, fine lines, large pores and “orange peel skin” in lower half of face? (photo)

Hi mrberney,
With the aging face, there comes a time for discussion about surgical intervention over all the available nonsurgical options. This is difficult to do without a formal consultation and exam. However, based on your description of what you're seeing and the photo provided, I would likely discuss with you doing a complete laser facelift versus a formal face and neck lift. The laser facelift I perform using SmartLipo to tighten the skin from the underside followed by Fraxel CO2 laser to the surface. Nonsurgical options, including aggressive chemical peels and filler will usually get you about half the result of a surgical option. Good luck in your search!
Sincerely,
Dr. Howland

Unfortunately, the one photo provided of the lower third of the face does not permit any comments about sagging neck. Crepeyness, fine lines and overall suggestion of loss of elasticity are, however, evident in the lower third portion of the face shown in the photo. While a series of superficial chemical peels can be helpful in refreshing the skin, diminishing dullness and sallowness and increasing its sheen and reflectivity, this usually requires a series of four to eight peels and in my experience full strength glycolic acid peels (not mild ones) to achieve any real improvement. Other peels that may be used are varying concentrations of TCA, Jessner's solution and full strength salicylic acid. But again, all of these require a full series of peels to achieve more prolonged benefits, and not simply one or two treatments. That being said, the crepey and crinkly appearance are unlikely to be improved much by peels. Instead, the use of hydrating injections of hyaluronic acid in the form of Skin Boosters, Hydromax or Volite (all of which I use in my Israel satellite facility,where a far greater number of regulatory agency approved injectable products are available) are good choices for this. In my Manhattan practice, I would opt for Restylane Silk. Properly performed, you may experience some tightening of the skin, as well. Individual etched-in lines, may additionally be addressed with a filler, such as Belotero Balance, which possesses little to no significant tendency to give rise to the unwanted bluish/gray Tyndall Effect when injected superficially in the skin. Microneedling may further help to improve very superficial color and textural irregularities. If indeed the neck requires work, you may check out the archives of RealSelf.com for a discussion of The Nonsurgical 3D Vectoring Necklift.  Make sure to consult with a board certified aesthetic physician. Best of luck. 

A great option for you would be laser resurfacing, that would address your fine lines, skin texture, and skin tightening. I would suggest combining it with dermal fillers for more lifting and volume replacement.  If you are considering treatment of the lower jawline into the neck area, Infini RF would be a great procedure to look into.  Your skin type would do well with many different modalities.  I would highly recommend consulting with a board certified dermatologist, where he/she can help you with your overall skin care goals.