Liposuction of the Face and Neck 

Updated: Apr 13, 2016
Author: Manoj T Abraham, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA 

Overview

Background

Cervicofacial liposuction involves the application of negative pressure through a hollow cannula in the subcutaneous plane to gently avulse fat cells and precisely sculpt undesirable fat deposits in the face and neck. In combination with other facial plastic and reconstructive procedures, lipocontouring provides a versatile tool in the facial plastic surgeon's armamentarium for achieving the desired facial profile.

The image below depicts liposuction of the face and neck.

The skin is tented and fed with the opposite hand The skin is tented and fed with the opposite hand in order to ensure smooth passage of the suction cannula in the appropriate subdermal plane.

History of the Procedure

Current liposuction techniques have evolved over many years. Initially, the direct excision of unsightly fat pads was described in combination with the superficial musculoaponeurotic system (SMAS) facelift.[1] Fat could be removed through the submental and postauricular rhytidectomy incisions, or excess ptotic fat and skin could be excised directly from jowls and wattles. However, because it is technically challenging to remove subcutaneous fat deposits in an even manner with open techniques, these attempts often produced uneven skin contour.

Historically, direct excision of skin and fat led to long visible scars that were predisposed to central depression and postoperative dog-ear formation. Given the often unsatisfactory results obtained with direct fat excision, it was not uncommon for surgeons to ignore preparotid, melolabial, submental, and neck fat accumulations, in many cases producing marked discrepancy in the rejuvenated appearance of the upper face compared with the lower face and neck.

During the past 20-25 years, the introduction of refined techniques for liposuction, in addition to platysma plication and surgical tightening of excess neck skin, has given the facial plastic surgeon the ability to provide improved mandible contour and cervicomental angle definition. Liposuction techniques are now an accepted part of most facial plastic surgeons' practices. The versatility of the liposuction procedure (used alone or in combination with rhytidectomy, malar and chin implants, genioplasty, and other adjunctive facial plastic procedures), combined with its excellent results, with only small cosmetically hidden scars, technical ease, and minimal morbidity and recovery time, has popularized its use.

More recently, the concept of liposculpture has come into vogue. Harvested fat is injected into areas that require fullness to complement the sculpting achieved by liposuction.

Problem

Although traditional rhytidectomy and other adjunctive facial plastic procedures address tissue laxity and can enhance the appearance of the bony framework, maldistribution of subcutaneous fat deposits can prevent precise draping of the skin. Lipocontouring techniques provide a means to shape neck and face fat deposits in order to better achieve the desired facial profile. The resulting overall improvement produces both direct and indirect effects on facial aesthetics. For instance, submental liposuctioning produces a more pleasing acute cervicomental angle and at the same time gives the illusion of enhanced chin projection.

Epidemiology

Frequency

With the continued advent of new and improved techniques and technology and the continued exposure and advertisement through the media and entertainment industry, facial plastic surgery has gained widespread acceptance and is growing in popularity. In 2009, nearly 10 million cosmetic surgical and nonsurgical procedures were performed in the United States.[2] Minimally invasive techniques that allow for quicker recuperation are especially in demand.

Current small-incision liposuction carries minimal morbidity and recuperation time and provides consistent lasting improvement in the facial profile. The techniques are easily learned and can be performed alone or in combination with rhytidectomy and other adjunctive facial plastic procedures. As a result, cervicofacial liposuction has gained popularity with both the patient consumer and the physician provider and is now routinely offered at almost every facial plastic surgery practice.

Etiology

Each individual's cervicofacial features are determined by the underlying bony and cartilaginous framework, and by the covering skin and soft tissue envelope. These characteristics are all ultimately determined at a genetic level but may be influenced to varying degrees by environmental factors (eg, nutrition, exercise, aging, medications, toxin exposure, actinic damage, trauma, surgery).

As adverse environmental factors exert their toll, ptosis of facial support structures causes drooping of malar and buccal fat pads. Loss of skin elasticity produces coarse and fine wrinkles and sagging of facial skin. Tissue laxity and the maldistribution of fat deposits lead to the formation of jowls and wattles, redundant loose tissue hanging from the mandible and chin respectively. In the neck, accumulation of fat and ptosis of the platysma results in prominent banding producing the "turkey gobbler" appearance. Patients with congenitally low-lying hyoid bones have further compromise of their cervicomental angle definition.

Pathophysiology

The normal aging process leads to bony resorption, decreased tissue elasticity, and altered distribution of fat deposits.[3] When combined with the sustained effects of gravity over time, these factors lead to ptosis of the cervicofacial support structures and the classic appearance of aging. Environmental factors may enhance or slow the aging process. Adequate nutrition and exercise may promote the appearance of youth, while exposure to radiation (eg, via sunlight, ultraviolet light tanning booths), toxins (eg, tobacco, alcohol), and trauma may contribute to premature aging.

Some individuals have a genetic propensity for undesirable facial fat distribution at a relatively young age, despite normal body weight. For instance, submental accumulation of baby fat may persist into adulthood. These patients usually have excellent skin and muscle tone and may benefit from selective closed liposuction alone.

Markman and others have popularized the currently accepted paradigm that fat accumulation in adulthood occurs by adipocyte hyperplasia rather then through cell division. Liposuction reduces the total number of adipocytes by directly removing cells and by inducing localized apoptosis as a result of mechanical trauma and devascularization. Adipocytes that remain after liposculpting are a stable population, and are no more prone to hyperplasia then adipocytes elsewhere in the body. As such, the improvement in facial profile after liposuctioning is maintained so long as generalized excess weight gain does not occur.

Presentation

The clinical presentation of patients requiring cervicofacial liposuction is influenced by the etiology of their perceived problem. Younger patients are more often interested in altering genetically inherited traits such as persistent submental baby fat. Older patients may desire a reversal of the appearance of aging and request smoothing of jowls and wattles, tightening of wrinkled sagging skin, or amelioration of a lax cervicomental angle and other hallmarks of aging.

Indications

No absolute indications exist for liposuction in the head and neck region. Patients desire this type of aesthetic surgery for a variety of reasons, both objective and subjective. Objectively motivated patients, such as when the surgeon and patient both agree a tangible cosmetic deformity can be improved by facial plastic surgery, are optimal candidates for surgery. Patients with diet-resistant cervicofacial fat deposits are ideal candidates for liposuction in this area.

Subjectively motivated patients, such as when the patient and surgeon are not in agreement on the need for surgical intervention, may portend an unhappy outcome despite a successful surgical result, and the surgeon should exercise caution before operating on these patients. Examples of these situations include patients who are coerced into surgery by a third party (eg, parent, spouse, significant other, business associate), or when the patient has an ulterior motive for surgery, either economic (eg, patient expects surgery alone to help scale the corporate ladder or result in a dream job offer) or social (eg, patient expects surgery to somehow help attract an uninterested partner or allow acceptance into a particular social circle).

No matter what the rationale for seeking surgery, patients must have realistic expectations for the outcome of the procedure.

Relevant Anatomy

Complete understanding of the complex skeletal, soft tissue, and neurovascular anatomy of the head and neck, gained by both didactic study and hands-on cadaver and clinical experience, is imperative prior to undertaking liposuction in this area. Although a comprehensive description of the anatomy of this area is beyond the scope of this article, relevant highlights are covered in this section.

As expected, underlying cartilage and bone determine the framework and ultimate appearance of the face and neck. In this context, the position of the hyoid bone in the neck is of particular importance. If the hyoid is located high in the neck and the overlying soft tissue is thin, has good tone, and drapes appropriately, a pleasing acute cervicomental angle results. On the other hand, if the hyoid is located congenitally low in the neck, liposuction and platysma plication of the overlying soft tissue and muscle still does not correct the obtuse cervicomental angle. To improve the bony contour in this area, a patient with a retruded or prognathic mandible may benefit from placement of a chin implant or a sliding genioplasty procedure, respectively, at the time of liposuction. Similarly, a patient who lacks prominent maxillary eminences can be augmented with malar implants.

Facial muscles provide the substance of much of the soft tissue covering of the face and neck. Decreased muscle tone and drooping can be improved with rhytidectomy techniques. In the neck, the tone of the platysma muscle contributes to the appearance of the cervicomental angle. During the aging process, the platysma tends to lose tone and become ptotic, resulting in prominent bilateral banding of the muscle in the neck. Using platysma plication techniques, the muscle can be reapproximated in the midline.

The parotid and submandibular glands, the 2 largest salivary glands, also impact on facial profile in this area. Pathology resulting in atrophy or hypertrophy of the glands is readily noticed. Submental and submandibular fat deposits accumulate below the mandible, and must be distinguished from glandular tissue. Care must be taken during liposuction in this region to remain superficial to the platysma to avoid injury to glandular parenchyma and ducts, which may result in the development of salivary collections and seromas.

The complex cervicofacial fascial planes provide much of the support structure for the soft tissue of the face and neck. The SMAS is an important component of this support structure, and plication of the SMAS is an essential step in the traditional rhytidectomy operation. Liposuction is carried out in the plane just superficial to the SMAS. The melolabial, buccal, and preparotid fat pads can all be found in their appropriate locations, contiguous with the SMAS.

Branches of the trigeminal nerve provide sensory enervation of the face. Both the inferior orbital and mental nerves are susceptible to injury during liposuction as they exit their respective foramina 0.5-1 cm below the inferior orbital rim and 1-1.5 cm above the lower border of the mandible. Although expansion of the sensory domain of surrounding nerves over the course of several months usually compensates for injury to these terminal sensory branches, a few patients may experience persistent numbness and paresthesias in the affected areas.

Transection or permanent injury to the motor nerve supply of the face and neck can be a devastating complication, particularly if it results in obvious asymmetry of facial expression. The marginal mandibular branch and the buccal branches of the facial nerve are predisposed to injury during liposuction because of their anatomical location. Because multiple terminal arborizing buccal branches are present, injury to small terminal branches in the midface may not result in significant deficits and is usually well compensated. However, damage to the marginal mandibular nerve during liposuction across the sharp angle of the mandible may cause unilateral paralysis of muscles to the lower lip and potentially result in a permanently asymmetric smile.

The arterial blood supply to the superficial face and upper neck arrives via the facial and temporal branches of the external carotid artery. A draining vein often accompanies the arterial supply. If blunt dissection during liposuction is carried out in the appropriate plane, injury to blood vessels of significance is unlikely, and the chance of postoperative hematoma is minimized.

In the neck, care must be taken to avoid perforating the platysma muscle with the liposuction cannula. Liposuction in this deep plane can very easily damage the abundant anterior subplatysmal plexus of veins, making it very difficult to obtain hemostasis. Superficial liposuction medial to the sternocleidomastoid muscles makes injury to the great vessels and cranial nerves of the neck less likely. Injury to diffusely distributed terminal lymphatics during liposuction is inevitable and probably contributes to postoperative edema. Pathologically enlarged lymph nodes merit appropriate therapy and investigation prior to undertaking liposuction in this area.

Contraindications

Although no absolute contraindications are specific to cervicofacial liposuction, the procedure should be undertaken with caution in patients who have had prior trauma or surgery in the area. Scar tissue and fibrosis may predispose the patient to neurovascular injury or damage to the subdermal plexus resulting in flap necrosis. In patients who are heavy smokers and those who have dermatologic, collagen, vascular, or other systemic diseases that may compromise flap viability, surgery should be considered with caution. The motivation and psychologic state of the patient must be reviewed in order to judge the patient's ability to cope with the emotional toll of the operation, the recovery period, and permanent alteration in appearance. Patients who are not appropriate candidates should be dissuaded from having surgery and encouraged to seek appropriate counseling.

 

Workup

Laboratory Studies

Perform routine preoperative lab work based on the patient's age and medical history.

Imaging Studies

As in all facial plastic surgeries, preoperative and postoperative photo documentation is essential. Computer modeling of projected outcome may be helpful in molding patient expectation. A thorough history and well-performed physical examination obviate the need for radiologic imaging studies (CT scan, MRI) in patients who do not have other concomitant disease.

 

Treatment

Medical Therapy

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.[4] 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.[4]

Surgical Therapy

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.

Preoperative Details

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.

Intraoperative Details

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.

A 6-mm straight suction cannula commonly used in c A 6-mm straight suction cannula commonly used in cervicofacial liposuction. Note the atraumatic blunt tip design.
A small 1-cm puncture incision is made in the midl A small 1-cm puncture incision is made in the midline, hidden within the submental crease, using a number 11 scalpel blade.

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.

The skin is tented and fed with the opposite hand The skin is tented and fed with the opposite hand in order to ensure smooth passage of the suction cannula in the appropriate subdermal plane.

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.

Limits of dissection in the neck with the suction Limits of dissection in the neck with the suction cannula (dotted blue line) in a patient undergoing closed cervicofacial liposuction. Note the superior margin of undermining (angle of the mandible) and the lateral margin (anterior border of the sternocleidomastoid muscle). Dissection in this patient extends down to the level of the thyroid notch, but it may be carried down as far as the sternal notch.

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.

Gentle negative pressure is applied manually with Gentle negative pressure is applied manually with a 10-cc syringe. Withdrawing the plunger continuously to produce a 1- to 2-cc vacuum creates and maintains suction.

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.[4] 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]

Postoperative Details

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.

Follow-up

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.

Complications

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.[7]

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.[8] 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.[9] 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).[10] The first study published in the English literature described its use for herniating lower lid fat pads in 2001.[11] 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.[12] A randomized, controlled study showed significant reductions in abdominal fat volume and thickness with serial PD-DC injections, with few minor adverse effects.[12] 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.[13]

For patient education resources, see the Procedures Center, as well as Liposuction.