Liposuction of the Face and Neck Treatment & Management
- Author: Manoj T Abraham, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA more...
Prior to considering any cosmetic surgery, patients with cervicofacial fat accumulation who are significantly overweight should be referred to a medical doctor who can implement appropriate changes in diet, exercise, and lifestyle to reduce the patient's serious health risk. Such patients have diffuse subcutaneous fat in multiple layers, which is difficult to address with liposuction.
Exercise to improve muscle tone, good nutrition, and avoidance of toxic substances, such as cigarette smoke, are means of maintaining a youthful appearance, but they are not substitutes for the dramatic change that may be achieved with surgery.
In addition to healthy lifestyle changes, the current market in the aging US population has driven a demand for noninvasive approaches to facial and cervical rejuvenation. Commonly used noninvasive treatments will focus on the treatment of skin laxity in the cervicomental region but also in the midface and jowl region.
Radiofrequency (RF) devices, produced by a number of different companies, transepidermally deliver energy to the patient. The mechanism of action relies on the RF to induce tissue oscillation that subsequently produces nonablative thermal energy. The increased temperature of the dermis and epidermis results in increased collagen synthesis and deposition within the dermis. Advances in technology have resulted in very sensitive instruments that can maintain a uniform and consistent dermal thermal endpoint, thus optimizing results and minimizing patient discomfort and complications. Newer products on the market, such as Ulthera, use high-frequency focused ultrasound that results in thermal ablation to the deep dermis and subcutaneous fat.
For patients interested in obtaining a tangible alteration in their appearance and who have reasonable expectations, current liposuction and facial plastics techniques provide an excellent means of achieving predictable, lasting cosmetic results. Choosing the most appropriate procedure is vitally important in ensuring a successful result. A younger patient with good skin tone may benefit from closed cervicofacial liposuction alone, but an older patient with significant skin laxity and underlying structural ptosis must have concurrent rhytidectomy to obtain an optimal outcome.
A complete and thorough preoperative evaluation is essential. Obtain a detailed history documenting the patient's perception of the problem. Explore all aesthetic concerns fully. Elicit a history of previous facial trauma or surgery. Take a history of smoking, alcohol or substance abuse, salivary disorders, and relevant systemic problems into consideration. All anticoagulant medications (eg, nonsteroidal anti-inflammatory drugs [NSAIDs], heparin, warfarin [Coumadin], vitamins, herbal supplements) must be discontinued appropriately prior to surgery.
Perform a thorough physical examination with special attention to the location and characteristics of undesirable cervicofacial fat deposits. Evaluate skin texture, tone, and quality by look and by palpation. Evaluate scars for propensity to keloid. Record the presence and extent of skin wrinkles, cigarette and actinic damage, altered pigmentation, and vascular and dermatologic lesions. Significant pathology that is discovered may merit further investigation prior to cosmetic surgery. Determine facial muscle tone, symmetry, and function, and document the presence of dehiscent platysmal banding. Test facial sensation. Assess the size, shape, and feel of the parotid and submandibular glands. Evaluate the structure of the bony facial skeleton and the position of the hyoid bone in the neck.
After taking a complete history and performing a thorough physical examination, an appropriate operative plan can be formulated that takes the patient's expectations of surgery into account. For the young patient endowed with good skin and muscle tone who complains of persistent facial fat deposits, closed liposuction in isolation may be sufficient (see Intraoperative details).
Older patients with fat accumulation and ptosis of the facial support structures usually require rhytidectomy in addition to open liposuction and platysma plication. In patients with other facial structural deficiencies, adjunctive facial plastic procedures (eg, mentoplasty, maxillary augmentation, cheiloplasty) may be necessary in conjunction with liposuction to achieve the optimal desired result. Meticulous photo documentation is helpful in operative planning and necessary for follow-up, medicolegal, and learning purposes. Computer modeling of projected outcome can be helpful in grounding patients' expectations, with the caveat that the final result depends on individual healing and may not exactly duplicate the projection.
The risk of complications must be carefully reviewed and documented during the informed consent process. Limitations imposed by the patient's anatomy should be discussed prior to surgery. For instance, the patient with a low-lying hyoid bone must be made aware that some improvement in the cervicomental angle is certainly present after liposuction and platysma plication but not to the extent seen in the patient with an elevated hyoid position. A patient with the classic "chipmunk" appearance of the lower third of the face as a result of parotid hypertrophy (due to medical causes such as alcohol abuse, benign lymphoepithelial cysts) must know that liposuction alone does not provide an improved contour in this area.
The following technique for liposuction of the face and neck is practiced by the authors. The patient is marked while sitting upright, to fully appreciate the effects of gravity. Important landmarks are noted first (margin of mandible, mastoid tip, medial border of sternocleidomastoid muscle, hyoid bone, thyroid cartilage, cricoid and trachea, and sternal notch). Areas of fat accumulation are then circumscribed, and zones of feathering indicated.
The choice of anesthetic is determined by patient and surgeon preference and is based on the type of procedure being performed as well as the patient's health and temperament. When closed cervicofacial liposuction is performed alone, the authors favor local anesthesia and nerve block with monitored sedation. If liposuction is performed in conjunction with rhytidectomy or other more extended procedures, general anesthesia with either laryngeal mask or endotracheal intubation should be considered.
Adequate local anesthesia and vasoconstriction is achieved using 0.5% lidocaine hydrochloride with 1:200,000 epinephrine and the usual injection and aspiration technique. Infraorbital, mental, and cervical plexus nerve blocks can supplement anesthesia, but do not provide vasoconstriction. In the awake patient, diluting the acidity of the injection with bicarbonate, warming the solution to body temperature, using a small caliber needle (25-gauge or smaller), timing maximum sedation to correspond to the time of anesthesia infiltration, and injecting slowly, all serve to minimize the initial pain of injection. Care should be taken to avoid grossly distorting the anatomy with the injection. The timing of local administration should be planned appropriately to allow maximum anesthesia and vasoconstriction, especially if multiple procedures are to be performed.
Closed cervicofacial liposuction
Closed liposuction can be performed in isolation or as the first step in the face-lift procedure. To accommodate a 4- or 6-mm blunt-tipped suction cannula, two small 1-cm puncture incisions are made within relaxed skin tension lines: (1) in the midline along the submental crease and (2) bilaterally along the postauricular sulcus just behind the earlobe along the standard rhytidectomy incision line, as depicted in the images below. In patients with prominent preparotid or melolabial fat deposits, additional incisions along the temple, hidden within the hairline, and along the nasal vestibule may be required to access these regions.
In patients undergoing a facelift with platysmal plication, the submental incision may be used. The correct superficial subcutaneous plane is accessed by lifting the skin with a skin hook and limited sharp dissection with scissors. The remainder of the dissection is carried out using the blunt-tipped suction cannula (first, without applying suction) to create subcutaneous tunnels. Multiple passes are made in a radial fashion from each incision, serially cross-hatching the areas of fat deposit. With each pass, the cannula is gently guided by tenting and feeding the overlying skin over the tip of the cannula with the opposite hand, as depicted in the image below. The authors prefer not to use cannulas with sharp dissecting edges to avoid injury to the skin and neurovascular structures. Similarly, to preserve the neurovascular supply to the skin flap and to avoid postoperative contour deformities, the authors do not advocate sweeping the cannula from side to side to break bridging soft tissue connections.
In the neck, dissection is carried from the submentum to the level of the anterior border of the sternocleidomastoid muscles laterally and down to the sternal notch, as depicted in the image below. In the face, undermining is performed as necessary from the area of the temples laterally to the melolabial folds medially and inferiorly to the level of the mandible. Great care is taken throughout to avoid injury to the branches of the facial nerve, especially along the mandible where the marginal mandibular nerve is at particular risk.
Once dissection is complete and the skin flap is appropriately freed, closed liposuction is performed in a similar crosshatched pattern. Gentle, controlled negative pressure can be applied manually with a syringe drawn back 1-2 cc, as depicted in the image below, or with a commercially available suction aspiration machine or operating room wall suction set at -700 mm Hg (approximately 1 atm). Several hundred passes are made with the port of the cannula facing away from the dermis. This avoids injury to the overlying skin flap and results in an even contour without scarring and pitting. Care must be taken to feather liposuctioning with surrounding areas in order to provide a final even profile and avoid an operated look.
If closed liposuction is performed alone, the skin incisions are closed in layers using simple 5-0 Vicryl dermal stitches, followed by simple 5-0 nylon stitches to reapproximate the skin edges. A light compression dressing is then applied.
Open liposuction with rhytidectomy
If rhytidectomy is to be performed, it is carried out in standard fashion, extending the incisions already created for closed liposuction. At the conclusion of the facelift procedure, prior to redraping the skin, persistent irregular fat deposits can be excised under direct vision with open liposuction. The blunt-tipped suction cannula may be used, but suction must be provided by machine vacuum because maintaining an adequate suction seal is not otherwise possible with the open technique. Remnant fat accumulations over the parotid, lower cheek, mandible, and neck can be further smoothed in this way. Particular attention is paid to the area parallel to the mandible to achieve an even mandibular contour.
If prominent platysmal banding is evident, platysma plication is performed to help further define the cervicomental angle. Using the cervicomental incision, the platysmal bands are released by sharp scissor dissection bilaterally under direct vision. The ptotic platysmal bands are then tightened by overlapping and approximating the muscles across the midline using interrupted 4-0 permanent sutures, proceeding up superiorly from the level of the hyoid. As discussed in Relevant Anatomy, a sharp cervicomental angle is difficult to achieve if the hyoid bone is positioned low in the neck.
Once liposuction, platysma plication, and rhytidectomy are complete, the skin flaps are redraped and tailored appropriately. Adjunctive procedures, such as placement of malar or chin implants and sliding genioplasty, can be performed concurrently. If significant oozing is encountered during the dissection, placement of closed suction drains should be considered. The rhytidectomy incisions are closed in standard fashion, and a circumferential compression facelift dressing is applied.
Additionally, new technologies are emerging to facilitate the success of submental liposuction. Ultrasound-assisted lipoplasty uses ultrasonic cavitation to minimize trauma to the local blood vessels, thus minimizing postoperative ecchymosis and bruising. Furthermore, in patients with both skin laxity and submental adiposity, laser-assisted lipolysis has been used. The laser energy produces fat and blood vessel coagulation. Simultaneously, there is stimulation of the overlying dermis with resultant skin contraction through dermal injury and subsequent neocollagenesis.[5, 6]
Patients who have undergone uncomplicated cervicofacial liposuction alone can be discharged home with adequate supervision. If rhytidectomy or more extensive procedures are performed and if closed suction drains are required, consideration should be given to observing the patient overnight. Head of bed elevation and the application of ice packs serve to reduce postoperative edema. All suction drains must remain free of clot and function appropriately. Patients are advised to remain on bedrest for the first night.
Analgesics are used liberally to maintain patient comfort, and patients are monitored carefully for any evidence of wound hematoma. If the patient complains of significant pain refractory to usual analgesic doses, the facelift dressing should be removed and the operative site carefully examined for the possibility of hematoma.
If a hematoma is discovered, it may be evacuated directly by making a small stab incision through the overlying skin, or it can be milked out through an adjacent incision by removing a few stitches. Extensive hematomas or hematomas that reaccumulate may require a return to the operating room to directly isolate and control the source of bleeding.
Perioperative antibiotics are used to decrease the chance of postoperative wound infection. Intravenous and oral hydration is encouraged because some tissue edema and third space loss of fluid occur as a result of cervicofacial liposuction, though not to the extent seen with body liposuction.
On the first postoperative day, the skin flaps are carefully assessed. The suction drains are usually removed if the drain output has decreased sufficiently and no evidence of hematoma is present. A lighter compressive facelift dressing is placed, and the patient is told to avoid all strenuous activity for the next few days. The preauricular and submental stitches are removed 5 days after surgery, and the remaining stitches are removed after 10 days. An elastic support bandage is worn around the cheek, chin, and neck for 2 weeks continuously after the operation, and then at bedtime for another 2 weeks. The patient is advised to limit movement of the head and neck and to maintain a neutral facial expression. Some degree of postoperative bruising and edema is expected, and generally only lasts a few weeks.
Gentle facial massage and ultrasound treatments may be used after 2-3 weeks to soften any developing scar tissue and fibrosis. At this time, the patient is encouraged to use postoperative nontoxic, noncomedogenic makeup and to style hair to camouflage incisions in order to speed the recovery process and to enhance the feeling of well-being. Elevated skin may be numb for as long as 1-2 months. Occasionally, precise injection of a small amount of steroid (dilute triamcinolone) into hypertrophic areas may be required to achieve a smooth, even contour. Care must be taken to avoid overuse of steroid injection, which can cause significant skin thinning, pitting, and depressions.
Postoperative photo documentation is obtained at 3, 6, and 12 months. Final healing with resolution of edema and the lift provided by scar contracture may not be evident for as long as 1 year after the procedure.
As with any surgery, patients need to be aware of the chance of complications following liposuction. Potential short-term and long-term complications include postoperative edema, hematoma, infection, scarring at the port incision sites, poor skin draping, necrosis of the skin flap due to subdermal plexus injury, underlying skeletal or soft tissue irregularities resulting in unsatisfactory final contour, and nerve injury resulting in paresis or paresthesias. However, in experienced hands, the risk of these complications is minimal.
Adamson reported a low complication rate in 47 consecutive patients undergoing liposuction, 43 of whom had other adjunctive procedures performed at the same time (38 concomitant rhytidectomies). Of these, 3 patients (6%) had localized wound complications (hematoma, flap necrosis, hypertrophic scarring). The authors also describe postoperative psychiatric depression as a complication in 3 patients.
Outcome and Prognosis
When the techniques described in this article are used, the vast majority of patients undergoing liposuction of the face and neck are happy with the outcome of surgery. In his series of 47 consecutive patients, Adamson reported no patients who were dissatisfied with their liposuction result. Other studies reported in the literature mirror this success rate. This favorable result is in a large part predicated by ensuring that patients understand the goals and limitations of cervicofacial liposuction and have realistic expectations of surgery.
Future and Controversies
The practice of cervicofacial liposuction is continually evolving, and many authors have proposed modifications to the techniques described in this article. A study by Innocenti et al indicated that neck rejuvenation can safely and effectively be performed through wide-undermining neck liposuction carried out under local anesthesia. The surgery, performed on 118 patients in the study, involved undermining the submandibular and neck regions in a wide rhomboid shape, with a thin layer of fat preserved. Improved neck contour was reportedly achieved in all cases, although the study advised that patients be selected based on age and anatomical features in order to obtain good cosmetic results.
Flynn and others advocate tumescent liposuction, a technique in which a large volume of normal saline mixed with dilute lidocaine and epinephrine is infiltrated into the subcutaneous plane with a blunt-tipped injector prior to commencing liposuction. These authors believe that ballooning of the subcutaneous tissue and fat aids in tunneling within the right plane, encourages hemostasis, and helps harvest fat in a less traumatic manner. However, tumescent liposuction does result in significant distortion of the anatomy, making it more difficult to judge the degree of fat removal needed to achieve the desired symmetric facial profile.
Adamson notes that Newman and others have recommended subplatysmal liposuctioning to better define the cervicomental angle and buck jowl liposuctioning via an intraoral or sublabial approach to excise ptotic fat in the buccal space. The authors' opinion is that the risk of injury to vascular structures and the marginal mandibular nerve is significantly increased by performing liposuction deep to the platysma. Aggressive suctioning in this area may also lead to depressions and uneven contour of the platysma. Care must be taken if liposuctioning via an intraoral approach to avoid injury to terminal branches of the buccal nerve and to prevent salivary contamination of the entire dissection plane predisposing to infection.
Gross and others have recently advocated liposhaving as a superior alternative to liposuction. With liposhaving, commercially available soft tissue shavers (often employed in endoscopic surgery) are used instead of the liposuction cannula to sharply amputate fat deposits sucked into the shaver with minimal suction. Great care must be taken to activate the blade only when the shaver is in continuous motion and in the appropriate location, in order to avoid overresecting fat and macerating skin edges. In the right hands, liposhaving is quicker and less labor-intensive then traditional liposuction. However, the safety of this technique with respect to damage to surrounding soft tissue and neurovascular structures must be proved unequivocally before it can be recommended for general use.
Another technique, mesotherapy, or injection lipolysis, was developed in Europe but has not been approved by the US Food and Drug Administration (FDA). The first study published in the English literature described its use for herniating lower lid fat pads in 2001. The most common preparation used is a phosphatidylcholine and deoxycholate (PD-DC) injection. While the exact mechanism of action is unknown, the PD-DC injections are thought to induce adipocyte necrosis. A randomized, controlled study showed significant reductions in abdominal fat volume and thickness with serial PD-DC injections, with few minor adverse effects. While research has been promising, however, the popularity of mesotherapy in the United States will remain limited due to lack of FDA approval and concerns about safety and collateral tissue effects.
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