Cervicofacial Fat Reduction and Augmentation

If one were to read this textbook from cover to cover and write down 10 important facts that they have gleaned from these chapters, one of these would be the importance of fat for not only youthful appearance, but also the caution of removing excessive fat during cosmetic procedures. Fat provides youthful volume, and loss of fat causes deflation with aging ( Fig. 15.1 ). Understanding the importance of reducing or augmenting the face and neck with fat is imperative. As highlighted earlier, the youthful face has plentiful midfacial fat volume and tapers to a youthful jaw and neck profile, whereas the aging face becomes deflated, which allows accumulation of fat deposits on the jawline and neck. This deflational shift coupled with other hard and soft tissue changes is in short what produces aging changes.

Numerous intrinsic and extrinsic factors influence the hard and soft tissue changes that occur throughout life. The main goal of rejuvenation is to reestablish the tapered face of youth. Treatment varies depending on the age of the patient. Younger patients may benefit from simple volume inflation with facial fillers and implants, while older patients will require fat removal and sculpting as well as skin tightening or removal. Injectable fillers, facial implants, and fat transfer have been detailed in previous chapters, and the remainder of this chapter will deal with fat reduction, recontouring (sculpting), and augmentation in the face and neck. It is very common for cosmetic surgeons to remove fat in some areas and add fat in other areas in the same procedure.

Anatomy

The malar fat pad supplies the majority of youthful midfacial volume and is discussed in Chapter 7 . The buccal fat pad (BFP), also called Bichat’s fat pad , provides facial volume and is a distinct and separate structure from the malar fat pad. Teleologically, the function of the BFP is not singularly defined. Theories include that the buccal fat aids in nursing and also forms a gliding plane to facilitate movement of the masticatory muscles and to cushion and protect the muscles ( Fig. 15.2 ).

Fig. 15.2, Infants have large buccal fat pads that, in theory, may aid in nursing (left) . The buccal fat pad can be resorbed quickly in malnutrition states, as shown in this emaciated child (right) .

The BFP sits between the buccinator muscle and the masseter muscle and should never be confused with the malar fat pad. The BFP is an encapsulated adipose mass that spans the lateral face from the temporal region to the mandibular region. Depending on the specific text or article, it has three lobes and four extensions. The temporal extension envelops the temporalis muscle on both sides, the body of the pad occupies the space under the zygoma, the pterygoid extension is in the region of the posterior maxilla, and the buccal extension sits inferiorly over the mandible ( Figs. 15.3–15.5 ). The parotid duct pierces the BFP on its intraoral entry ( Fig. 15.3, 15.4 ). The BFP can herniate with aging and can be approached intraorally or through the facelift incision during rhytidectomy ( Figs. 15.7 and 15.8 ).

Fig. 15.3, The buccal fat pad sits between the buccinator and masseter muscles. The parotid duct pierces the fat pad, and the facial nerve branches are in proximity. m , Muscle; n , nerve; SMAS , superficial muscular aponeurotic system.

Fig. 15.4, The buccal fat pad sits between soft tissue layers. m , muscle; n , nerve; SMAS , superficial muscular aponeurotic system.

Fig. 15.5, The buccal fat pad is shown in relation to the bony anatomy. The dotted line represents a portion of the mandibular ramus cut away to show the underlying fat pad.

Fig. 15.6, A 45-year-old female patient (left) and a 60-year-old female patient (right) both exhibit herniated buccal fat pads.

Fig. 15.7, A herniated fat pad is shown through a rhytidectomy approach.

Diagnosis

Buccal fat reduction (BFR) is a procedure that can assist in reducing facial fat in selected patients. The procedure can assist to trim and taper the cheek area but is not a procedure that will make a fat face skinny. This is an important point as many young patients seek this procedure with the intent to slim their entire face. BFR is more of a precision procedure used to sculpt the cheek area in selected patients. It is requisite for the surgeon and patient to understand the realistic results of BFR. This has become a popular procedure with millennials, and social media has propagated the notion that a chubby face can be “sculpted.” It is not uncommon for some of these patients to think that such a small procedure will give them a face like a fashion model. It is a big mistake to operate on a patient with such expectations. BFR is a procedure that can lure patients with body dysmorphic disorder. The surgical result is obviously related to the size and volume of the BFP. The area of reduction is in the mid to lower cheek ( Figs. 15.8 and 15.9 ).

Fig. 15.8, This patient with a large buccal fat pad is shown at the time of reduction through the intraoral approach (left) . The approximate area of effect seen with buccal fat pad reduction is shown (right) .

Fig. 15.9, The typical area of fat reduction with buccal fat reduction is shown (left) . An indention from traction on the buccal fat pad during a reduction procedure also illustrates the most distal area of the cheek that will be affected by buccal fat reduction (right) .

The importance of what this procedure will do and which areas will be affected is paramount to patient communication as many patients have inflated ideas of what this procedure does. Patients who cannot understand that this procedure is conservative are not operative candidates. This is one procedure in which I always underpromise in terms of results. Sometimes the results are very noticeable, and other times they are very subtle. This is obviously influenced by the amount of buccal fat the specific patient possess.

Contrary to the belief of many patients, the entire BFP is never removed. It is generally the buccal extension and body that is reduced and sometimes a portion of the pterygoid extension. The goal with this procedure is reduction and not ablation. This adipose mass is important in providing youthful facial volume, and overzealous excision will skeletonize the patient.

Although it is not possible to provide a completely accurate prediction of the surgery result, having the patient lightly create a vacuum and slightly suck in their cheeks will produce a concavity in the region of the BFP ( Fig. 15.10 ).

Fig. 15.10, Asking the patient to general gently suck in their cheeks will make a depression in the generalized area of the buccal fat pads. This must be done with very little suction as not to overestimate a possible result.

Surgical Procedure

Although this is a simple procedure, the BFP can be very elusive, especially for novice surgeons. Like most of the procedures we perform, the operation becomes easier with experience.

Very similar to blepharoplasty, doctors claiming that the patient does not have a BFP usually translates into they just could not find it. I perform a lot of these procedures, so I can generally find the fat pad in a matter of seconds, however selected cases can be more difficult. I have never not been able to find a fat pad, although in some patients it is much smaller than in others.

BFR can be easily performed with local anesthesia or intravenous sedation. The first step is to infiltrate the proposed incision site with local anesthesia. Approximately 2 mL of 2% lidocaine with 1:100,000 epinephrine is infiltrated just under the parotid duct (Stenson’s duct) into the mucosa. The duct is located opposite the first molar region on the cheek mucosa. On some patients it is very easy to see, and on others the orifice is more hidden. Several more milliliters of local anesthetic are infiltrated into the buccinator muscle (which is just submucosal) and into the generalized region to be reduced. I prefer to make the incision several millimeters below the parotid duct. In general, the BFP is easily located and reduced, but location can be challenging in some patients,. My first approach is always through the infraductal incision. If the fat cannot be located through this incision, my secondary mucosal approach (pterygoid approach) is more superior and lateral to the second and third molars in the maxillary sulcus.

As stated, a 4- to 5-mm-wide incision is made with a radiofrequency microneedle just through the mucosa several millimeters under the parotid duct ( Fig. 15.11 ). This area is very vascular, and a coagulative incision modality is preferred. The actual incision is made only through the mucosa as the vascular buccinator muscle can bleed significantly, and this is sometimes difficult to coagulate. The parotid and buccal branches of the facial nerve traverse the BFP, so blind coagulation is not desirable.

Fig. 15.11, The parotid duct (dotted circle) and the marking for the buccal fat pad reduction several millimeters below the duct are shown (left) . A mucosal incision with a radiofrequency microneedle is performed (right) .

After the incision is made through the mucosa, a long, thin tonsil clamp is used to bluntly puncture through the buccinator muscle. This is a perfect instrument for atraumatic entry through the muscle, and the delicate curved tips are efficient to spread and grasp the fat pad. After the hemostat punctures the buccinator, the tips are spread within the buccal space, and the fat will frequently billow out of the incision ( Figs. 15.12 and 15.13 ). It is very common to secure a small lobe of the BFP, and once it is teased out of the capsule or incised, the other lobes pour out into the incision, much like blepharoplasty fat pads. As stated earlier, the parotid and buccal branches of the facial nerve traverse this area, so gentle manipulation is required ( Fig. 15.14 ).

Fig. 15.12, The tonsil clamp piercing the buccinator muscle (left) and the clamp spread to grasp the buccal fat pad (right) .

Fig. 15.13, After the hemostat is spread and gently clamped, the buccal fat pad is delivered into the oral cavity. Numerous attempts at gentle spreading and closing of the hemostat may be necessary before the actual fat pad is located.

Fig. 15.14, The parotid duct on each side is shown in the same patient. It is usually not visualized but may present when performing larger incisions.

Angling the hemostat slightly superolaterally can be helpful in locating the fat pad. Placing digital pressure on the cheek skin and manipulating the fat pad to the incision is helpful to capture the fat if it does not readily present ( Fig. 15.15 ). Once delivered, the fat pad is then secured with another pair of hemostats under slight traction ( Fig. 15.16 ). Usually this reveals more fat, and the second pair of hemostats is placed at the base and traction applied. This reciprocal procedure is repeated and allows the majority of the fat to be teased out of the capsule into the incision.

Fig. 15.15, Pressing on the lateral cheek may assist in the delivery of the buccal fat pad in cases in which securing the fat is challenging.

Fig. 15.16, The right and left buccal fat pads are delivered by teasing the fat out of the incision with hemostats, replacing the other hemostats at the base with gentle traction, and then repeating this procedure until no more fat is readily delivered.

If the fat does not present itself, the hemostat is repositioned superolaterally, and spreading is continued. If the fat pad mass is still not located, a 3- to 4-mm suction tip can be inserted while the assistant pinches the suction hose. The suction is then directed superolaterally, and the hose is unpinched to activate the suction. This maneuver will frequently engage the fat pad and pull it from the incision ( Fig. 15.17 ). Once secured, the buccal pad may present in various configurations in given patients ( Fig. 15.18 ).

Fig. 15.17, A blunt, tapered tip suction is inserted through the wound in a superior lateral position with the suction source clamped (left) . The buccal fat pad is retrieved after the suction source is unclamped (right) .

Fig. 15.18, The buccal fat pad can assume various morphologies in given patients. Some patients have a very lobular buccal fat pad (left) , some have more of a pannus configuration (center) , and others have a firmly encapsulated buccal fat pad (right) .

If the surgeon cannot locate the fat pad through the parotid duct incision, a pterygoid approach is performed in which a more superior incision is made in the sulcus lateral to the second and third molars, and the hemostats are introduced and guided inferolaterally ( Fig. 15.19 ). Spreading the tips of the hemostats and employing the suction as described may be necessary in the pterygoid approach as well. Fig. 15.20 shows the BFP in place as viewed through an upper-right cheek implant incision.

Fig. 15.19, In this patient, the buccal fat pad could not be located with an infraductal buccal incision (left, B) . A pterygoid incision (P) was made lateral to the distal molars, and inferior lateral dissection with the hemostats located the pad (right) . I usually begin with an infraductal buccal incision; if I cannot locate the pad, I proceed to the pterygoid incision.

Fig. 15.20, The encapsulated right buccal fat pad as viewed from an upper right cheek implant incision.

Once the available fat is delivered into the oral cavity, it is reduced with bipolar forceps or an electrosurgery tip at the base for coagulation ( Fig. 15.21 ). It is important to use a coagulative modality as vessels penetrate the fat pad in the same manner as blepharoplasty.

Fig. 15.21, It is important to coagulate the base of the buccal fat pad to control bleeding. Failure to do so could cause a postoperative hematoma. Radiofrequency bipolar forceps were used for coagulation (left) , and an electrosurgery microneedle was used as an alternate means of coagulation (right) .

The end point of buccal fat reduction is gauged in a similar manner to blepharoplasty. The excess fat that readily presents itself with minor traction and superficial exploration is removed. Additional contributions to the end point are the lack of additional fat delivered into the mouth and visible depressions at the site of the BFP ( Fig. 15.22 ). Performing BFR is very similar to blepharoplasty in that overresection can produce a skeletonized appearance. Facial fat is a friend and not an enemy, and reduction should be judicious. Generally removing all of the easily available fat that herniates into the oral cavity with suction or moderate traction is sufficient for a noticeable clinical result.

Fig. 15.22, Bilateral depressions are visible immediately after buccal fat pad reduction (arrows) . This is one of the signs used to gauge the end point of the procedure.

Before transection, a photo is taken of the BFPs when delivered into the mouth. A photo is also taken of the excised specimen ( Figs. 15.23 and 15.24 ). This is done for medical records and also because every single patient is interested in how much fat was removed.

Fig. 15.23, Photos are taken not only intraorally but also of the excised specimen for the patient’s medical record and interest.

Fig. 15.24, Although significant fat is removed, the actual specimen appears much smaller. A large buccal fat pad reduction in one patient (top) and a smaller amount in another patient (bottom) are shown.

After sufficient fat is removed, the surgical site is checked for hemostasis. The buccinator muscle at the incision site is a frequent source of bleeding and can contribute to a hematoma. If active bleeding is encountered deeper in the wound, cauterization must be carefully addressed as facial nerve branches can be in the proximity as they traverse the masseter muscle. Packing the wound with gauze can also assist in hemostasis. Wound closure is performed with one or two 4-0 gut sutures.

Postsurgically, gauze packs are placed between the cheeks, and a compressive dressing is placed for 24 hours. This dual-layer compression assists in eliminating dead space and may assist in control of bleeding and swelling ( Fig. 15.25 ).

Fig. 15.25, The postoperative dressing includes gauze packs between the cheeks (which are removed several hours later) and a compressive facial dressing for 24 hours. The intraoral gauze tails are tucked externally to prevent swallowing or aspiration.

Recovery is generally minor, although some patients may experience significant edema. Patients are told to avoid bending, lifting, or any activity that produces the Valsalva maneuver and to expect an approximately 1-week recovery.

Figs. 15.26–15.34 show before and after cases of BFR. Although plentiful fat can be removed bilaterally, the clinical result is subtle, and it is sometimes difficult to see a big difference in before and after images. Most frequently the patient can appreciate a change regardless of photos and is happy. Patients must be informed preoperatively that the changes with average BFR are small to moderate. Patients with inflated presurgical expectations are not good candidates.

Fig. 15.26, This patient is shown in the right three-quarter view before (left) and after (right) buccal fat pad reduction.

Fig. 15.27, This patient in Fig. 15.26 is shown in the left three-quarter view before (left) and after (right) buccal fat pad reduction.

Fig. 15.28, The surgical specimen from the patient in Fig. 15.26 .

Fig. 15.29, This patient is shown in the right three-quarter view before (left) and after (right) buccal fat pad reduction.

Fig. 15.30, The patient in Fig. 15.29 is shown in the left three-quarter view before (left) and after (right) buccal fat pad reduction.

Fig. 15.31, The surgical specimen from the patient in Fig. 15.29 .

Fig. 15.32, This patient had extremely heavy cheek and buccal fat pads. The patient is shown before facelift with a simultaneous buccal fat pad removal (left) and after the procedure (right) .

Fig. 15.33, This patient is shown before (left) and after (center) facelift surgery. Although her neck was greatly improved, the buccal fat pads prevented this case from being acceptable. The patient is shown after buccal fat pad removal (right) .

Fig. 15.34, Intraoperative photo of the patient in Fig. 15.33 during facelift surgery shows herniated buccal fat pads (left) and the excised buccal fat overlaying its approximate location (right) .

Complications

As stated, judicious dissection and grasping must be performed because related anatomic structures such as the parotid duct and large vessels can traverse the cheek ( Fig. 15.35 ). Minor punctures or lacerations can be treated with a simple suture closure. In the case of severe laceration or transection of the parotid duct, cannulating the parotid duct orifice with an intravenous cannula assists in stabilizing the sutured repair and maintaining patency of the duct. The cannula is sutured to the cheek mucosa and left in place for several days.

Fig. 15.35, A partially transacted parotid duct was damaged during buccal fat reduction in this patient. The laceration was repaired with 5-0 gut suture, and the patient progressed without problems.

The buccal fat reduction procedure traverses some very vascular structures, and brisk bleeding can occur. This is problematic as the buccal branch of the facial nerve and the parotid duct preclude aggressive blind coagulations. In the case of excessive intraoperative bleeding, hemostatic gauze can be packed into the surgery site and left for 10 minutes ( Fig. 15.36 ). This usually will assist in controlling bleeding and allowing exploration. Failure to control intraoperative bleeding can lead to hematoma formation ( Fig. 15.37 ).

Fig. 15.36, Hemostatic (combat) gauze is placed through the incision to pack the surgical site for hemostasis.

Fig. 15.37, This patient sustained an intraoperative hematoma during buccal fat pad reduction. Close attention must be paid to hemostasis throughout the procedure to prevent intraoperative or postoperative hematoma.

I have witnessed temporary buccal branch paresis from this procedure. Infection is a possibility, but I have not witnessed any.

Cervicofacial Liposuction

Joe Niamtu, III

The subcutaneous planes in the face and neck have a distinct layer of fat in young and fit individuals. Deeper fat deposits such as the BFPs and the subplatysmal submental fat also contribute to youthful facial volume ( Fig. 15.38 ). With aging and weight gain, patients can accrue large amounts of subcutaneous and deep fat ( Fig. 15.39 ).

Fig. 15.38, The typical area of subcutaneous submental fat deposition (left) and the relative position of the subplatysmal fat deposit (right) are shown.

Fig. 15.39, A special-effects “fat suit” can be worn by actors to simulate fat deposition (left) . This patient demonstrates how much fat can accumulate in the cervicofacial region (right) .

Liposuction is an effective procedure for fat reduction and one of the most commonly requested cosmetic procedures. Although it can be very effective in the face and neck, it is not a treatment for obesity. Liposuction is more indicated for sculpting of specific areas such as the neck, jowls, and jawline. It is important that patients understand the limitations of isolated cervicofacial liposuction. All of my consents detail not only the expected results, but also “what your procedure will not do.” Cervicofacial liposuction is most effective for small, isolated fat deposits that are resistant to weight loss.

Anatomy of Liposuction

Lobules of fat are separated by fibrous septae that contain neurovascular structures and lymphatics. The individual fat cells contain triglyceride, and in weight gain the fat cell increases in size. Weight loss from diet and exercise can decrease the quality of the fat cells (decrease in intracellular fat) but not the quantity (number of fat cells). Liposuction removes the actual fat cells, and these cells will no longer contribute to fat increase; therefore the results are permanent in this context. When the fat cells are removed with the cannula, the septae remain intact, giving the region a “Swiss cheese” appearance ( Fig. 15.40 ).

Fig. 15.40, In “open” liposuction during facelift surgery, fat cells are removed, and the fibrous septae remain intact.

Skin tightening can occur with tumescent liposuction by unknown means, although it is believed to relate to posttraumatic fibrosis and collagen ratcheting and or shrinkage. Younger patients have a better skin-tightening response to liposuction than older patients. It is important for patients to understand that removing fat can lead to skin excess, especially in older patients. Many patients present with submental fat and cervical skin excess and request liposuction. By removing the fat in this region, a volume reduction occurs that can create more skin excess. Although submental liposuction may be very effective in a younger patient with increased fat and minimal skin excess, it could be problematic in an older patient with excess skin. In these cases, facelift surgery is necessary to address the skin.

Tumescent Anesthesia

Tumescent liposuction was a true paradigm shift in cosmetic surgery and enabled safe and predictable fat sculpting with local anesthesia. The basic functions of tumescent anesthesia are hydrodissection of tissue planes allowing for more accurate treatment, hemostasis from the epinephrine and tranexamic acid, and local anesthesia from the lidocaine. Body liposuction patients may receive up to 6 L of tumescent solution, and there are much more significant fluid balance considerations than in the face and neck, where much smaller volumes are used. Typical tumescent anessolution consists of 1 L of saline or lactated Ringer’s solution with 1 g of lidocaine and 1 mg of epinephrine (1:1000 concentration). Over the past several years I have begun adding 1 g of tranexamic acid to the mixture as well. Because an entire liter of solution is usually not necessary for facial procedures, the components can be halved for a 500-mL volume ( Fig. 15.41 ).

The areas of intended liposuction are marked with the patient in the upright position before surgery or administration of tumescent anesthesia. Commonly treated areas are the submental regions, jowls, jawline, and lateral neck.

After the patient is prepped, tumescent anesthesia is infiltrated. I prefer a Klein pump with a 22-gauge spinal needle ( Fig. 15.42 ). Alternately, a dedicated blunt infiltration cannula may be used and is a better choice for novice surgeons as it is less traumatic. Hypodermic syringes can be used in place of a peristaltic pump. The tumescent solution is injected in the subcutaneous plane.

Fig. 15.42, A Klein peristaltic pump (left) with a 22-gauge spinal needle is an efficient means of infiltrating tumescent solution. Experienced clinicians may use an 18-gauge spinal needle. A simple 60-mL syringe with an 18-gauge needle is an affordable means of tumescent injection (right) .

Approximately 100 mL of tumescent solution is infiltrated into the submental region, about 50 mL on each submandibular region and about 30 mL over each jowl ( Fig. 15.43 ). The tumescent solution is injected, and the patient is prepped and draped, which gives the tumescent time to percolate through the tissue planes in a process called detumescence . When the surrounding skin is blanched, the patient is ready for the procedure ( Fig. 15.44 ).

Fig. 15.43, This patient is shown during tumescent anesthesia infiltration for facelift surgery (left) . The approximate distribution of the tumescent fluid for a comprehensive case is demonstrated (right) .

Fig. 15.44, These patients are shown approximately 15 minutes after tumescent anesthesia infiltration. The skin is blanched in the tumesced regions, signaling anesthetic effectiveness.

Liposuction Instrumentation

As opposed to body liposuction, the relatively small volumes of fat removed during cervicofacial liposuction (15–30 mL) only require basic instrumentation. Although a dedicated liposuction pump is generally used for body liposuction, standard wall suction will suffice for face and neck liposuction as the fat accumulations are much less ( Fig. 15.45 ).

Fig. 15.45, A commercial liposuction aspirator can be used for large-volume body liposuction (left) . Standard wall suction generally is all that is necessary for cervicofacial liposuction (right) .

Liposuction cannulas (cannulae) are available in a vast array of sizes, shapes, and configurations. The selection is more varied for large-volume body liposuction, but the instrumentation is simpler for the face and neck ( Fig. 15.46 ). If liposuction is performed in a “closed” manner (i.e., from a puncture), then the entire region is under negative pressure and more efficient. This means that small cannulas of 1–2 mm can be used to sculpt isolated regions of fat, and 2–6 mm cannulas can be used for larger collections. When “open” liposuction is performed, it is generally through a larger incision or flap under direct vision. This means that the area to be treated is not under negative pressure, and fat removal is directly visualized ( Fig. 15.47 ). Larger cannulas can be used in these situations if large fat deposits exist. I frequently use a 6-mm cannula for open submental liposuction with generous fat deposition.

Fig. 15.46, Common liposuction cannulas for face and neck treatment vary from 1–6 mm.

Fig. 15.47, Closed liposuction is performed through a small puncture (left) , while open liposuction is performed through an incision or elevated flap under direct vision (right) in facelift surgery.

The basis of the liposuction procedure is to place the correct cannula in the correct tissue plane to reduce the correct fat deposit ( Fig. 15.48 ). This basically means that most facial liposuction is performed in the subcutaneous plane, and hydrodissection from the tumescent injection helps define this plane. Small deposits warrant smaller cannulas and vice versa. It is always important to keep the orifice of the liposuction cannula facing away from the dermal surface. Failure to do so can create contour irregularities and grooves from dermal damage. It is also important for the operator to keep in mind relevant anatomy as facial nerve branches and vessels can be injured with liposuction.

Fig. 15.48, Typical areas of fat deposition that respond to liposculpture are shown. Liposuction above the mandibular border should be performed only by experienced surgeons.

The suction hose is pinched (or aspirator turned off) during entry into the puncture site as not to damage the skin. Once the cannula is inserted into the puncture site in the subcutaneous plane, the suction is activated, and the cannula is kept in continual motion. A rapid, reciprocal, to-and-from motion is performed while observing how much fat is exiting the suction tubing and the clinical improvement of the treated site. This is best thought of as a sweeping motion similar to sweeping a carpet with an electric vacuum. The operator should cover a single area with multiple strokes, while trying not to repetitively overlap the same area. Several strokes over the same area are acceptable, but the goal remains a homogenous sculpting treatment over the entire region. With small fat deposition, a single series of strokes may be all that is required, whereas large depositions may require several “passes” of strokes. Marking the patient to indicate the larger areas of fat deposition is efficient as more fat removal will be performed in these areas.

Some surgeons advocate right-angle intersections of the cannula to create a cross-hatch pattern for liposuction. This may allow better removal and contour but is probably more relevant for large-volume body liposuction than for the face. Liposuction is best thought of and referred to as liposculpture because it is important to gently sculpt and reshape the treated regions as opposed to simply emptying them.

It is important (especially for novice surgeons) to be able to judge the end point of treatment. Part of this judgment is a learned tactile experience. Pinching the skin and fat between the finger and thumb before, during, and after the cannula strokes can help judge the amount of fat present and remaining ( Fig. 15.49 ). This also allows the surgeon to ensure that the skin thickness is homogenous over the entire treatment region. It also helps guide the fat to the cannula tip and allows the surgeon to feel the fat going up through the cannula. Careful observation of the suction tubing is also important. If generous yellow fat is coming through the tubing, the target and removal is effective. When the fat stops coming out or when blood tinged fat is seen (or blood without fat) then the end point is present or near.

Fig. 15.49, Pinching the skin over the cannula during liposuction assists in determining the end point of fat removal and makes suctioning more efficient by moving fat toward the cannula tip.

Submental Liposuction

The submental and anterior cervical regions are the most common areas of the face for liposuction treatment. Many patients have generous fat in this region, and the results can be striking in selected patients. The most important patient screening factor is the age of the patient and amount of skin laxity present. Younger patients with isolated fat deposits and no excess skin are optimal candidates. Although liposuction can produce skin tightening, the larger the amount of skin excess and the older the patient, the less dramatic the result will be. Fig. 15.50 shows candidates with optimum anatomy for successful submental liposuction, and Fig. 15.51 shows poor candidates for submental treatment.

Fig. 15.51, Older patients with submental fat and excess neck skin are poor candidates for submental liposuction.

Also relevant to the final result are patients with large subplatysmal fat deposits. Although some surgeons advocate liposuction of the deep subplatysmal fat, it is less effective in my experience. Open submentoplasty is much more dramatic. The target fat with common liposuction is shown in Fig. 15.38 .

Submental liposuction is generally performed between the sternocleidomastoid muscles from the mandibular border to the thyroid cartilage region ( Fig. 15.52 ). The intended region of treatment must be marked in the upright position before surgery and tumescent infiltration. When performing liposculpture on the submental area, the cannula is navigated as previously described with rapid reciprocal motions across the regions of fat deposition ( Fig. 15.53 ). Using the palm of the nonsurgical hand to stretch the tissue caudally facilitates the procedure. The surgeon and staff can stretch the submental neck skin to assist in pulling the skin in the opposite direction of the cannula motion ( Fig. 15.54 ). This facilitates using a straight cannula on a normally concave surface. Feathering the treatment by treating heavier fat more aggressively and tapering the removal as the depositions thin out toward the periphery provide a homogenous treatment. This is, of course, different for each patient, but as a rule the larger deposits are in the midline between the mandibular border and the thyroid cartilage region. Fig. 15.55 shows the copious amount of fat that can be removed from this region.

Fig. 15.52, Submental liposuction is generally performed from the mandibular border (blue) to the thyroid cartilage region between the sternocleidomastoid muscles (red) . The yellow region indicates the regions of usual fat deposition. Heavier patients may require a larger treatment area.

Fig. 15.53, Submental liposculpture is performed with rapid, reciprocal cannula movement across the region of intended treatment (left) . The inferior border of the mandible is also treated from this approach to improve definition (right) .

Fig. 15.54, Although this image is from an open submentoplasty, it illustrates that stretching of the neck skin makes it easier to navigate this concave region with straight instrumentation. Having the surgeon and the assistant stretch the skin facilitates liposuction in this area.

Fig. 15.55, Generous fat is removed from the submental area with a 6-mm liposuction cannula. Fat removal from this region varies from 5–30 mL in the average patient.

Liposculpture along the mandibular border can assist in defining this region ( Fig. 15.56 ). Having a fullness at and above mandibular border with a sculpted inferior mandibular region produces a more youthful appearance.

Fig. 15.56, Liposculpture is performed under the mandibular border for definition. Fat above the mandibular border is less commonly treated, with the exception of the jowl.

Surgeons must always remember that fat is our friend, and overtreatment can lead to severe aesthetic problems that are very difficult to improve. Normal skin is pliable with a layer of subcutaneous fat. If excessive fat is removed, the dermis can adhere to the underlying platysma and other tissues, creating hollowness, webbing, and banding ( Fig. 15.57 ).

Fig. 15.57, These patients were treated by other surgeons with excessive fat removal. Hollowness and banding occurred from dermal adhesion to deeper tissues, creating a very problematic situation that is difficult to repair. Subcutaneous fat is important for a gliding plane of underlying structures.

Jowl Liposuction

Along with excess neck skin, jowl formation is one of the most disdained aging changes that begin to manifest in the late fourth decade. Jowling results from both skin and deep tissue ptosis but also from fat accumulation. Careful attention must be paid to jowling during facelift surgery. If a perfect facelift is performed but excess jowling is not addressed, the result can be a tight neck and face with big lumps on each jawline. The jowl region can harbor a surprising amount of fat, and this is frequently underestimated by novice surgeons. It is important to keep in mind that the marginal mandibular nerve frequently underlies the jowl region, and caution must be used in this region ( Fig. 15.58 ). The marginal mandibular nerve course is in a subplatysmal plane, so keeping the liposuction cannula in this plane should provide safety in this region.

Fig. 15.58, The marginal mandibular nerve generally courses inferior to the mandibular border posterior to the antegonial notch (green arrow) but crosses the mandible anterior to the notch and travels along the mandibular border in the jowl region (dotted circle) .

Patients who require submental liposuction frequently require simultaneous jowl liposuction, and some surgeons treat both areas from a submental puncture ( Fig. 15.59 ). Although this can be effective, the previously described marginal mandibular nerve courses this region. Sometimes in an effort to reach the jowl from the submental region, the surgeon will lever the cannula over the mandible to gain access to the jowl. This levering can compress the soft tissues between the cannula and mandibular bone with force (see Fig. 15.59 ). It is possible to injure the marginal mandibular nerve in the process, and I believe it is safer to approach the jowl from an earlobe incision and approach it without levering forces. Also, it is difficult to reach the deeper jowl fat through the submandibular approach.

Fig. 15.59, Approaching the jowl from the submental region can possibly produce a crush injury from levering the cannula against the mandible (green arrow) and injure the marginal mandibular nerve (left) . Approaching the jowl from an earlobe incision (right) eliminates this potential problem and also allows easier recontouring of the deeper jowl tissues and mandibular border.

To access the jowl from an earlobe incision, a stab incision is made at the junction of the lobe and cheek with a scalpel or awl. Iris scissors are then used to expand the puncture into the subcutaneous plane, and the cannula is then advanced across the mandibular border without suction until the jowl region is reached ( Fig. 15.60 ). At this point, the suction is activated, and the jowl is reduced with reciprocal cannula movement.

Fig. 15.60, An earlobe incision is made at the junction of the lobe and cheek, and the cannula is advanced without suction until the jowl is reached. It is important not to use active suction while advancing to the jowl, or a groove can be created along the mandibular border.

In some patients (especially older ones), the jowl extends both above and below the mandibular border, and it is important to treat both regions for a natural rejuvenation ( Fig. 15.61 ). Although copious amounts of fat can be removed from the jowls, overtreatment remains a possibility, and a conservative approach should always be used for natural rejuvenation ( Fig. 15.62 ). Treatment of isolated jowls can reduce them but rarely eliminates the jowl. Patients must be given realistic expectations, such as a 25% to 50% improvement.

Fig. 15.61, The jowl can extend above (yellow) and below (green) the mandibular border (white line) . It is important to address the inferior fat below the mandibular border as well.

Fig. 15.62, Significant fat can be removed from the jowls in some patients. Surgeons should always be vigilant about overtreatment and continually monitor the result during fat removal, or a depression can result.

The neck and mandibular border and cheeks can be approached through an earlobe incision, but expanded liposculpture in these areas should be reserved for experienced surgeons ( Figs. 15.63 and 15.64 ).

Fig. 15.63, The mandibular border and lateral neck can be treated through an earlobe incision.

Fig. 15.64, Other areas of the face can be liposculpted from the earlobe incision. Experience is required to treat these areas and should be approached cautiously by novice surgeons.

As discussed earlier, open liposuction is performed with direct visualization, usually with facelift surgery or platysmaplasty ( Fig. 15.65 ). In this situation, the surgeon can actually see the fat being reduced before their eyes, which is evidence of the effectiveness of the procedure. With open liposuction, in-and-out reciprocal motion can be used, but lateral movement of the cannula is also very effective in this area because it is not restricted by vacuum or skin, as in closed procedures.

Fig. 15.65, “Open” liposuction is used to describe the fat reduction process with a suction cannula under direct vision.

Postoperative Liposuction Care

Liposuction is generally a straightforward recovery but can be painful because of disruption of the nerve endings. It is important to compress the areas that have been treated to prevent dead space with accumulation of blood or blood products, which can reorganize and decrease the effectiveness of the procedure. I generally ask the patient to wear a compression dressing for 1 week as much as they can and then for an additional week during sleep. A variety of facial compressing dressings are available, however, a simple elastic bandage tied in a bow makes an efficient, cost-effective, and unobtrusive compression dressing ( Fig. 15.66 ). Figs. 15.67–15.73 show before and after photos of cervicofacial liposuction patients.

Fig. 15.66, A simple elastic bandage makes a cost-effective, efficient, and unobtrusive means of applying compression to the submental and jowl region after liposuction.

Fig. 15.67, This patient underwent cervicofacial liposuction with a simultaneous chin implant.

Fig. 15.68, This patient underwent submental and jowl liposuction only.

Fig. 15.69, This patient underwent cervicofacial liposuction with a simultaneous chin implant. She is shown 5 days after the procedure.

Fig. 15.70, This patient underwent submental liposuction and had an excellent result. This is a good example of the skin tightening that can occur in younger patients.

Fig. 15.71, The patient in Fig. 15.69 is shown in the right three-quarter view.

Fig. 15.72, This patient underwent cervicofacial liposuction with a simultaneous chin implant.

Fig. 15.73, This patient underwent cervical facial liposuction only.

Assisted Liposuction and Liposuction Alternatives

The scope of this chapter prohibits a discussion of every available liposuction alternative. As technology progresses, numerous “assisted” liposuction or fat-reduction devices have appeared. These include power-assisted liposuction (PAL) in which the cannula is motorized in reciprocal movements, laser-assisted liposuction (LAL) in which fat is melted with a specialized cannula, ultrasonic-assisted liposuction (UAL) in which ultrasonic waves destroy the adipocytes, and water-assisted liposuction (WAL) in which the cannula tip employs a water jet to disrupt the adipocytes. Cryolipolysis is now a popular technique and works by applying an external cooling device over the skin to cool the fat cells noninvasively to a temperature that kills the cells, which are then resorbed by the body. Cryolipolysis can be effective, but I see many patients who are disappointed with their results for the price of the treatments. Although some of these devices are useful, others are less impressive compared with traditional cannula liposuction.

Mesotherapy or chemical fat reduction has been practiced off-label for decades with variable results and significant complications. In 2015, Kybella (deoxycholic acid) was approved by the US Food and Drug Administration (FDA) for the treatment of submental fullness. This drug was taken to the FDA by Kythera, Inc. and purchased by Allergan in October 2015. Kybella is injected in the subcutaneous fat and destroys the cell wall of the adipocytes. The contents are absorbed by the body and eliminated by natural processes. In my experience, it requires multiple procedures and is much slower and less effective than liposuction.

Technology is a great thing, especially when some of these devices can assist in skin tightening. I still feel that despite these technological advances, conventional cannula liposuction still remains the safest, most efficient, and most cost-effective treatment for small regions such as the face, neck, and jowls.

Submentoplasty

Isolated submental surgery consisting of liposuction of preplatysmal fat, direct reduction of deep platysmal fat, buccal fat reduction, and midline platysmaplasty is an effective procedure for patients with isolated submental fullness without jowling or midface aging changes. This procedure is best performed on younger patients with little to no excess neck skin and isolated submental fat. Minor jowl fat can also be addressed. A chin implant is also a useful adjunct to this procedure to enhance the profile and cervicomental angle if indicated. Submentoplasty is not a panacea and must be used on a specific patient type. These patients need more than simple liposuction but less than a facelift. Most patients do not fall into this category, but isolated submentoplasty can be very effective in the right patient.

Submentoplasty begins with buccal fat reduction and jowl liposuction (if indicated) and proceeds with undermining the submental skin in the same manner as platysmaplasty ( Figs. 15.74–15.76 ). A thick flap is elevated because much of the underlying fat will be removed. Allowing sufficient fat on the flap prevents contour irregularities. Once the flap is elevated, any excess fat overlying the platysma is removed or liposuctioned. Liposuction is also performed along the inferior border of the mandible and in the jowl regions if necessary. Access is then made between the anterior bellies of the digastric muscles, and the deep platysmal fat is reduced. The platysma is addressed by midline platysmaplasty or by platysectomy, depending on preference and experience. Submentoplasty is a fun and interesting procedure because it is a combination of numerous small procedures that can add up to a very impressive result in correctly selected patients.

Fig. 15.74, Buccal fat pad reduction in jowl liposuction are commonly performed at the same time as a classic submentoplasty.

Fig. 15.75, Undermining of the submental skin (left) , the region after liposuction of preplatysmal fat (center) , and the deep platysmal fat being directly resected (right) are shown.

Fig. 15.76, A midline platysmaplasty is shown (left) . A chin implant may be placed when indicated (right) . The sum total of these procedures can add up to a dramatic result.

Conclusion

Cervicofacial fat reduction is a mainstay of cosmetic facial surgery. The most important factor is choosing the right patients when performing isolated procedures. Fat management during facelift produces more dramatic results because of the skin removal and redraping. Removing isolated fat in patients with skin excess can be problematic. Overtreatment with any fat-reducing technology can produce complications that are difficult to improve. Novice surgeons should begin with young patients who have isolated fat deposition and minimal skin excess and gain experience ( Figs. 15.77–15.78 ).

Fig. 15.77, This 16-year-old male patient underwent submentoplasty with buccal fat reduction, jowl liposuction, submental liposuction, deep platysmal fat resection, and midline platysmaplasty.

Fig. 15.78, This 26-year-old female patient with genetic premature aging underwent submentoplasty with buccal fat reduction, jowl liposuction, submental liposuction, deep platysmal fat resection, and midline platysmaplasty and chin implant.

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