Medical Therapy
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]
Surgical Therapy
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]
Preoperative Details
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.
Patient aged 35 years. Left – Preoperative. Right - 4 months postoperative, liposuction of 25 mL from submental area and jowls with chin implant on right.
Patient aged 36 years. Left – Preoperative. Right - 4 months postoperative, liposuction of 150 mL from submental area and jowls.
Woman aged 45 years. Left – Preoperative. Right – Postoperative, liposuction of neck and jowls and excision of thyroglossal duct cyst.
Woman aged 58 years. Left – Preoperative. Right - 5 months postoperative, liposuction of 100 mL of fat from neck.
This 50-year-old woman underwent liposuction of the submental and jowl areas, as well as the pretragal zones. 200 cc was suctioned. The photos on the right were only 3 weeks postoperative. Additional skin tightening and resolution of swelling is expected.
Intraoperative Details
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.
Postoperative Details
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.
Follow-up
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.
Patient aged 35 years. Left – Preoperative. Right - 4 months postoperative, liposuction of 25 mL from submental area and jowls with chin implant on right.
Patient aged 36 years. Left – Preoperative. Right - 4 months postoperative, liposuction of 150 mL from submental area and jowls.
Woman aged 45 years. Left – Preoperative. Right – Postoperative, liposuction of neck and jowls and excision of thyroglossal duct cyst.
Woman aged 58 years. Left – Preoperative. Right - 5 months postoperative, liposuction of 100 mL of fat from neck.
This 50-year-old woman underwent liposuction of the submental and jowl areas, as well as the pretragal zones. 200 cc was suctioned. The photos on the right were only 3 weeks postoperative. Additional skin tightening and resolution of swelling is expected.
Complications
An appealing aspect of this procedure is the low rate of complications.
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Infection should be rare (< 1%).
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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.
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Hypesthesia of the suctioned area is the rule and resolves by 3 months.
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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.
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Perforation of the skin is possible and may result in scarring.
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Perforation of the larynx, trachea, or carotid is a remote possibility and is operator dependent.
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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.
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Blistering, burns to the skin, scarring, and seromas are possible with the use of ultrasonography.
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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.
Outcome and Prognosis
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.
Future and Controversies
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.
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Patient aged 35 years. Left – Preoperative. Right - 4 months postoperative, liposuction of 25 mL from submental area and jowls with chin implant on right.
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Patient aged 36 years. Left – Preoperative. Right - 4 months postoperative, liposuction of 150 mL from submental area and jowls.
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Woman aged 45 years. Left – Preoperative. Right – Postoperative, liposuction of neck and jowls and excision of thyroglossal duct cyst.
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Woman aged 58 years. Left – Preoperative. Right - 5 months postoperative, liposuction of 100 mL of fat from neck.
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This 50-year-old woman underwent liposuction of the submental and jowl areas, as well as the pretragal zones. 200 cc was suctioned. The photos on the right were only 3 weeks postoperative. Additional skin tightening and resolution of swelling is expected.
