Liposuction of the Face and Neck

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 in order to ensure smooth passage of the suction cannula in the appropriate subdermal plane.

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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 few decades, 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. ^[2] 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.

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.

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 2020, about 15.5 million cosmetic procedures were performed in the United States. ^[3]  Minimally invasive techniques that allow for quicker recuperation are especially in demand. ^[4]

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.

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.

The normal aging process leads to bony resorption, decreased tissue elasticity, and altered distribution of fat deposits. ^[5] 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.

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.

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.

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.

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.