Submental and Jowl Liposuction

Liposuction of the neck and jowls (see image below) is clinically one of the most rewarding procedures in aesthetic surgery. With a short, low-risk, relatively inexpensive procedure, patients can achieve a dramatic change in their appearance. With recent technical advances, the results achieved with liposuction can, in many patients, rival those achieved with a facelift.

This article discusses the history, surgical technique, risks, and benefits of neck and jowl liposuction.

 

Liposuction of the submental area, neck, and jowl has been performed since the first description of liposuction in the late 1970s. Illouz performed the procedure prior to 1979, using a 5-mm cannula via a lateral approach.[1] Hetter described the use of smaller cannulae through a single submental incision.[2] In 1984, 2 additional sub-ear lobular incisions were made to allow for suction at a right angle to the submental suctioning. This lessened the chance of formation of visible ridges. It also decreased the chance of injury to the marginal mandibular nerve. By the mid-1980s, a 2.5-mm cannula was used. Suctioning of the cheeks, jowl, and mandibular border was added to neck suctioning to achieve a balanced result. Subplatysmal fat suctioning was added in 1987.

In the early years, neck liposuction was reserved for patients younger than 40 years, in whom skin shrinkage uniformly was expected. However, by the early 1990s, surgeons recognized that suction could be performed in older patients with an apparent excess of skin. The skin usually redrapes over the longer distance without hanging. This uses the geometric principle that the sum of 2 sides of a triangle is longer than the third side. In addition, surgeons realized that subdermal liposuction resulted in contraction of the skin.

Subcutaneous infiltration of the subcutaneous plane became standard by 1990, with varying concentrations of lidocaine and epinephrine used to provide anesthesia and hemostasis. Some surgeons have used internal and external ultrasonography since the late 1990s, although this technique has lost popularity over the last decade.

Recently, there has been a focus on skin tightening during and after liposuction. Devices such as laser-assisted liposuction and various forms of externally applied energy such as fractional lasers, radiofrequency and infrared radiation, and high-energy focused ultrasound (Ulthera) have been attempted.[3, 4, 5, 6] There is still not enough unbiased evidence with any of these techniques to be able to recommend them. Therefore, liposuction of the neck and jowls should be performed only when the skin is expected to spontaneously contract. Alternatively, if the patient is willing to accept loose, potentially hanging skin, liposuction can be offered with the appropriate warnings and informed consent. 

 

 

 

This problem comprises the triad of excess submental fat, jowl fat, and loss of the visible contour of the mandible. Fat in the submental region is usually related to obesity. However, fat may be present even in individuals of normal weight. As aging progresses, many people develop submental fat deposits independent of their weight. This may be more apparent as the skin loses elasticity and begins to hang. Similarly, jowl fat may be caused by excess fat or may be related to senescence. The etiology is similar for the loss of visibility of the mandibular border.

Accumulation of submental fat causes the cervicofacial concavity to decrease, eventually approaching a flat angle or convexity. While body fat may be hidden with clothing, fat in this area is the "giveaway" for obesity. A youthful neck is associated with a cervicofacial angle close to 118 degrees.

Jowls are a hallmark of aging faces and are present in most people by age 50 years. A loss of definition of the mandibular border also is a characteristic of aging, particularly in individuals who are overweight. In addition to removing fat, the procedure appears to stimulate the contraction of the skin, giving the appearance of skin removal.

Complicating the problem of submental fat is the difficult-to-diagnose subplatysmal fat and the often-present microgenia. A careful analysis of the precise issues the patient has is critical to obtaining an aesthetically pleasing result.  

Frequency

One of the most common regions suctioned is that of the submental area and jowls.[7] In the author's practice, 25% of liposuction procedures are performed in this area. The procedure may be performed alone, in association with a facelift or platysmaplasty, or with resection of the subplatysmal fat along with a platysmaplasty.[8]  Suction is often performed in combination with placement of a silicone chin implant using the same, albeit longer, incision.  

As with most cosmetic surgery, women are more likely to request liposuction of the neck and jowls than men. However, a large number of men do undergo this procedure. The age range for this procedure is wide (17-70 y or older). Patients younger than 40 years more often present with generalized, mild to severe obesity. Some patients in their late teens or early 20s have an isolated submental fat pad. Patients older than 40 years present with middle-aged mild weight gain associated with other early changes of aging (eg, periocular wrinkling).

For more information on aesthetic procedures, visit Medscape's Aesthetic Medicine Resource Center.

Consider patients with submental and jowl fat who request aesthetic improvement as candidates for this surgery. Skin elasticity should be good to fair to predict good retraction of the skin. Patients who are not candidates for facelift surgery because of ongoing smoking, diabetes, or other medical problems may be candidates for liposuction because of the lower complication rate, although caution should be exercised in these patients because of the risk of skin loss. In one study, localized midline fat was a better predictor of a good outcome than the age or the quality of the skin.[9] A "crepe paper" appearance of the skin was the best predictor of failure.[9]

As newer methods of noninvasive skin tightening become proven by scientific studies, the pool of candidates for liposuction of the neck may actually increase, allowing fat removal in patients with skin that previously would have been expected to hang after liposuction.

Patients who require more rapid recovery than a facelift allows may be candidates for suction. As a secondary benefit, patients with extremely corpulent necks may achieve medical benefits. After fat removal, the contour of the neck may allow for easier intubation if general anesthesia is necessary in the future.

Liposuction of the jowls and submental areas is usually performed in the preplatysmal plane. As the marginal mandibular nerve is deep to the platysma, no important nerves are at risk if the integrity of the plane is maintained. Note and avoid the external and anterior jugular veins. The submandibular salivary glands and platysmal banding are prominent. Of particular importance with the use of ultrasonic liposuction in the area, complete avoidance of the area of the facial artery and marginal mandibular nerve is mandatory.

Of note is that subplatysmal fat cannot be suctioned; its removal requires a longer incision and direct removal. Subplatysmal fat is usually removed in the central compartment, often leaving the medial and lateral fat pads behind.[10]  Subplatysmal fat may be identified by having the patient flex the platysma muscle while the examiner physically assesses the thickness of the subcutaneous fat. If the amount of palpable subcutaneous fat is less than expected, the remainder of the fat is likely subplatysmal. Tensing the platysma muscles is not easy for some people, and numerous facial grimaces may be necessary to fully assess the fat compartment.

Particular care should be taken in reoperative procedures, since the anatomy may have been altered with the prior procedure and because scar tissue will require greater force to the liposuction cannula, increasing the chance of deep penetration and injury.[11]

Relative medical contraindications include any illness that may place the patient at significantly higher risk for complications.[9] This includes cardiovascular, pulmonary, renal, hepatic, or endocrinologic disease. While the patient may accept the higher risks, the surgeon has the fiduciary responsibility to protect the patient from harm. If the patient has undergone prior neck surgery, liposuction may be ill advised. In this situation, scar tissue may necessitate more forceful suctioning, increasing the chance of penetration into underlying structures, with potentially disastrous consequences.

An alteration in normal anatomy may place the marginal mandibular nerve or deeper structures at risk. Aesthetic contraindications include poor skin elasticity, which may result in drooping skin. Note the platysmal banding. Consider concomitant platysmaplasty, since removal of the overlying fat can expose preexisting but hidden banding. Make note also of subplatysmal fat, which can be removed safely only with direct excision. Failure to remove this fat leads to patient dissatisfaction.

Preoperative laboratory tests include only those generally required for surgery.

• At a minimum, perform urinalysis to look for bacteria and glucose.

• Perform a hematocrit.

• Individualize other laboratory tests for the patient.

No particular imaging tests are required for this procedure. Obtaining good quality preoperative photographs is important for medicolegal reasons.

If underlying pathology is suspected based on the physical examination, then perform appropriate tests (eg, CT, MRI of the neck). Be wary of thyroglossal duct cysts, branchial clefts, thyromegaly, and other cervical pathology.

Medical therapy may provide an alternative to submental liposuction. In April 2015, the US Food and Drug Administration (FDA) approved deoxycholic acid (Kybella) for the reduction of submental fat-associated moderate to severe convexity or fullness (ie, double chin) in adults. The agent, which occurs naturally in the body, is a cytolytic that, when injected into tissue, destroys cell membranes. Deoxycholic acid was tested in numerous phase-3 trials, carried out in the United States and abroad, with 68.2% of patients having responded to the injections.[12, 13, 14, 15, 16]  However, reports of significant complications such as alopecia and nerve injury may have an impact on future use.[17]  Cryotherapy also is in vogue for submental fat reduction, but the results are small when compared with liposuction, with an average of 2.3 mm of fat being reduced on caliper measurements.[18]  

Liposuction is the treatment of choice for fat removal in the youthful neck and jowls. The alternative procedure, a facelift, is a longer procedure with a much lengthier recovery period, greater risks, and higher costs. Newer treatments, such as barbed suture jowl lifting, have repeatedly failed in their goal of jowl elevation.[19]

Preoperatively, patients usually are seen twice. Perform imaging using computerized image-morphing technology. This provides a better understanding of the patient's desires and the opportunity to simulate a realistic result. Caution is advised not to make the patient look better than anticipated, since patient satisfaction is related directly to preoperative expectations. Physically examine the neck to exclude unusual pathology such as a lipoma or a thyroglossal duct cyst. Distinguish preplatysmal (supraplatysmal) fat from subplatysmal fat; palpation should assist in making the diagnosis.

Ask the patient to depress the lower lip and show the lower teeth. This move tenses the platysma muscle, allowing easier examination to distinguish subcutaneous fat from subplatysmal fat. Have the patient suck in the buccal fat, thereby allowing the examiner to distinguish subcutaneous fat from buccal fat in the jowl. Buccal fat removal may be required if it comprises a significant portion of the jowl.

One cadaver study revealed that the mean weight of preplatysmal fat was 8.4 g, and the mean weight of the fat immediately deep to the muscle was 3.7 g.[20] In 15% of cases, the weight of the subplatysmal fat was greater than that of preplatysmal fat.[20] Distinguish the contribution of buccal fat pad to the jowls. Asking the patient to suck in the buccal fat pad assists in making this diagnosis. Facial grimaces assist in assessing the hidden platysmal banding.

Refer appropriate patients for medical clearance. During the second visit, perform a complete physical examination. Advise patients to discontinue aspirin-containing medications or other drugs that may inhibit clotting or interfere with anesthesia. To decrease the risk of deep venous thrombosis, the patient must discontinue use of oral contraceptives 1 month prior to surgery. Preoperative photographs are mandatory, as shown in the images below.

Make topographic maps of the patient's neck, submental, and jowl fat in the preoperative area. Mark the border of the mandible and the marginal mandibular nerve and jugular veins. Mark the fat and suction to the level of the laryngeal prominence. The procedure may be performed under local anesthesia (with or without sedation) or general anesthesia. Technically, the procedure is easier under local anesthesia because the endotracheal tube mechanically blocks the suctioning. Standard sterile technique is used encompassing the anterior hair line.

Use 0.25% lidocaine with 1:400,000 epinephrine to infiltrate the proposed incisions. Make 5-mm incisions in the submental crease and at the junctions of the ears and cheeks. Introduce a fine hemostat into the incisions to undermine the first centimeter of the neck. This allows for effortless introduction of the cannula, avoiding strong thrusting that could result in errant passes and subsequent injury. Inject a solution consisting of 200 mL of 0.25% lidocaine with 1:400,000 epinephrine through the incisions with a blunt-tipped needle. Approximately 150 mL of this solution is usually sufficient. Using diluted lidocaine is important because tumescent injection above the clavicles results in a rapid rise in plasma lidocaine concentration.

Once the skin has blanched (8-10 min), suction usually begins in the mid line, using a short 3-mm-triport cannula with the holes oriented inward. Perform pretunneling. Suction approximately two thirds of the neck through this incision, taking care to lift the skin with the cannula to prevent penetration through the platysma. Aggressive suctioning can be performed in the submental area. Place the cannula just beneath the skin with the holes pointed downward to prevent complete defatting. Do not try to suction all the fat; the concept is to sculpt the fat. Suction the jowls gingerly with a 2-mm cannula with the suction turned to half power. Oversuctioning this region causes a deformity that is difficult to correct. Suction the lateral neck region and jowls through the under-ear incisions and perform crosstunneling in the midline area.

If pretragal or cheek suctioning is necessary, perform it through these incisions. Making a small pretragal incision may be necessary if the tissue is very fibrous. Palpate the entire suctioned area carefully ("pinch test") to ensure complete fat removal. Small bits of remaining fat can be forcibly pinched between the thumb and fingers to disrupt them. This maneuver saves time and avoids fishing for tiny imperfections. Use the 2-mm cannula to feather areas adjacent to suction. Depending on the patient, 10-150 mL of fat is typically suctioned.

Following the liposuction, platysmaplasty or chin augmentation with implant can be performed to improve results, if indicated. If subplatysmal fat is to be removed, the submental incision must be several centimeters long. Remove this fat under direct vision. Take care to not create a submental hollow by overresecting this pad. Platysmaplasty is usually performed following subplatysmal fat removal.

Close the submental incision in 2 layers and dress it with bacitracin and an adhesive bandage. Use of Dermabond is not advised in this location because sutures allow for a small degree of drainage, thereby decreasing the amount of postoperative bruising. The incisions under the ears are left open; placement of sutures in this area increases the chance of a malpositioned earlobe. Place an appropriate compression garment. Smooth placement of the dressings and garment must be emphasized to prevent ridges from forming. Drains are not necessary. Elevate the head of the bed.

Keep the patient in the facility until medically stable. Discharge instructions include elevation of the head. A soft diet is advisable for several days. See the patient 1-2 days postoperatively and clean the incisions. The patient may begin showering the day following surgery. Give the patient a second compression garment so that one can be worn at all times except when showering.

Remove sutures 5-7 days postoperatively. At that time, ecchymosis is below the level of the mandible and an opaque makeup can be gently applied. The patient usually returns to work approximately 5-7 days postoperatively. The garment should be worn after work for an additional week. After 2 weeks, it is probably unnecessary.

As with all facial cosmetic surgery, err on the conservative side and do not allow elevation of blood pressure for 3 weeks postoperatively. The author allows lower body exercise at that time but warns against weight training or contact sports for another 3 weeks.

Massage is necessary with this procedure, as collections of blood and devitalized fat are frequent. Gentle manual manipulation—pushing, not rubbing—can begin at 3 weeks. The author tells patients to envision a piece of clay under the skin that they need to flatten. Gentle electric massagers are allowed but are usually not necessary. Lumps, which may take a full 3 months to resolve, are more likely with concomitant platysmaplasty and sometimes require dilute steroid injection to hasten resolution.  

See patients 3 weeks postoperatively to assess lumpiness and instruct in massage techniques. If lumps are visible, 0.1-0.5 mL of triamcinolone 10 mg/mL may be injected to hasten their resolution.

See patients 3 months postoperatively for photographs and assessment and 9-12 months postoperatively for the final visit. Stress the importance of keeping the head elevated, as small collections of blood may last for months and may result in subtle thickening of the subcutaneous tissue for nearly a year. Postoperative images are shown below.

An appealing aspect of this procedure is the low rate of complications.

• Infection should be rare (< 1%).

• The risk of expanding hematoma is low, although the risk of nonmedically significant hematoma is higher. Small collections of blood occur commonly (in as many as 10% of patients) and result in patient concern until resolution after several months. However, these are medically insignificant.

• Hypesthesia of the suctioned area is the rule and resolves by 3 months.

• Injury to the marginal mandibular nerve should be an uncommon, although possible, event. When it occurs, injury usually consists of bruising of the nerve with rapid return of function. Unless the cannula enters the subplatysmal plane, this nerve is not in direct danger.

• Perforation of the skin is possible and may result in scarring.

• Perforation of the larynx, trachea, or carotid is a remote possibility and is operator dependent.

• Aesthetic risks include rippling, dimpling, remaining fat, and removal of too much fat. Excessive defatting may result in adherence of the dermis to the underlying platysma. Approximately 5% of patients require a touch-up suctioning procedure. Repeat suctioning is extremely difficult because of intense scarring and increased risk of injury to surrounding structures.

• Blistering, burns to the skin, scarring, and seromas are possible with the use of ultrasonography.

• The risk of hanging submental or jowl skin causing deformity depends on the elasticity of the skin. Assess this preoperatively. Inform patients who have borderline elasticity of this risk and the possible need for a formal facelift to correct this problem.

The expected outcome from this surgical procedure is an improvement in the concavity of the cervicofacial angle. This gives the appearance of a more youthful neck and the striking appearance of weight loss. In older patients, the results of this procedure may approach those of facelifts. In the practice of aesthetic surgery, submental and jowl suctioning has one of the highest patient satisfaction rates with very low risk.

Liposuction of the submental area and jowls will continue to grow in popularity as the public realizes that it is a viable alternative to the more invasive facelifting procedure. Combined with laser resurfacing for fine wrinkle control and newer techniques (eg, high-energy focused ultrasound for skin tightening), the results may approach those observed with facelifting. Furthermore, the combination of midfacelifts, platysmaplasty, laser resurfacing, high-energy focused ultrasound, and the strategic use of volumizing filling agents, with liposuction of the neck, may further decrease the use of more invasive procedures.  

Liposuction assisted with the Nd:YAG laser has been performed by some surgeons.[7] The laser destroys cells and stimulates collagen formation. To date, however, this technique has not been proven better than conventional liposuction. The potential for complications is, however, greater, as skin tightening requires skin heating and there is a very small margin of safety between tightening and disastrous skin destruction.

For excellent patient education resources, see eMedicineHealth's patient education article Liposuction.