Fig. 24.27 (a) Preoperative 54-year-old female. (b) Six months following an aggressive submentoplasty with subplatysmal fat excision, platysmal resection, small chin implant, and partial

submandibular gland resection. Note the slight irregularity where the gland would normally have some residual bulging. Slight overresection of fat may have contributed to the minor irregularity

1.Difficult to control bleeding from branches of the facial artery

2.Thermal injury or neuropraxia to the marginal mandibular and other nerves in the region

3.The possibility of leaving the patient with xerostomia (low risk)

4.Increased risk of developing a seroma or hematoma

5.Risk of salivary fistula or sialoma (low risk)

24.12 Complications

24.12.1 Over-resection of Fat

Aggressive fat removal with cervical liposuction may result in a pleasing appearance initially but ultimately may result in fibrosis (Fig. 24.28). The term cobra neck deformity has been used to describe the central skeletonized look or hollow mid-submentum that results from over-resection. This deformity can also result from a relative under resection of fat laterally. This is a difficult problem to treat and can potentially result in litigation. We emphasize that it is important to leave at least 4–5 mm of fat on the skin flap and to avoid rasping the dermis with the suction cannula. One must be constantly aware of the orientation of cannula opening and its relationship to the dermis. The use of microcannulas 2–2.5 mm diameter decreases the likelihood of localized over-resection in the neck compared to larger instruments. Ensuring that the cannula is moving to a different location with each

pass is essential as is frequent analysis of the thickness of the tissue remaining. The goal in cervicofacial liposuction is to resculpt youthful neck contours while leaving an adequate amount of fat to avoid scarring and unmasking underlying structures such as the submandibular glands, platysmal banding, and digastric muscles.

Once contour irregularities have developed one must decide whether this can be corrected with additional adjacent liposuction or autologous fat grafting. Rarely, it may be necessary to elevate the skin flap to allow for redraping. Residual platysmal banding can be treated with Botulinum toxin Type A. Five unit doses injected into the band at intervals of 2 cm can be helpful [9]. Up to 20 units of Botox is typically required to treat each band. As with any liposuction case, it is much easier to take more out at a later time if needed versus trying to treat fibrosis or a depression due to overzealous liposuction.

24.12.2 Sialocele

The development of a sialocele after cervicofacial liposuction or submentoplasty is rare (<.05%). One would expect to see this more commonly after submandibular gland resection or aggressive facelifts. The sialocele can be a nuisance. Often the patient can swell extensively every time they smell food or get hungry. Immediate enlargement upon eating is diagnostic in most cases to distinguish this straw-colored fluid from a

laxity are poor candidates for isolated cervicofacial liposuction or submentoplasty. Usually, when there is residual skin laxity it is in the midline. For older men, a reasonable option may include a direct excisional submentoplasty with a Z or W plasty. These men often are not interested in a traditional facelift with its associated downtime and telltale scars. A traditional lower face and neck lift with submentoplasty remains the procedure of choice for significant lower face and neck laxity.

24.12.6 Chronic Pain

Chronic pain is usually not seen after cervical liposuction but can occasionally be seen after submentoplasty. Typically, this will resolve in a few months and can be a result of the tightness of a corset platysmaplasty. The pain also can be a result of irritation of sensory nerves and the character of the pain may help to identify this. Development of a neuroma must also always be ruled out. Medications such as Elavil, Neurontin, or Lyrica may be helpful in dealing with severe chronic neuropathic pain. Fortunately, most postsurgical pain is temporary in the neck.

24.12.7Post-inflammatory Hyperpigmentation

This is a problem that would be seen more commonly in patients with Fitzpatrick skin Types III or greater. With time, the hyperpigmentation almost always resolves without treatment. One can however speed up the resolution of the hyperpigmentation with the application of prescription grade strengths of hydroquinone (4% or greater) or kojic acid to the affected areas. Use of intense pulsed light or laser therapy to treat post-inflammatory hyperpigmentation is occasionally required.

24.12.8 Infection

Infections after surgical procedures in the head and neck area are rare primarily because of the excellent blood supply. When one suspects infection one should, if possible, obtain a specimen for gram stain along with

Fig. 24.29 Staph folliculitis after submentoplasty

cultures and sensitivities to guide antibiotic therapy. The most common organisms are typical skin flora, notably

Staphylococcus and Streptococcus (Fig. 24.29). Over the last decade there has also been a shift in the prevalence of methicillin-resistant Staphylococcus. Previously, this was hospital-acquired organism whereas now many methicillin-resistant Staphylococcus aureus (MRSA) infections are community acquired. The communityacquired MRSA is often sensitive to trimethoprimsulfamethoxazole and Clindamycin [37]. The initial gold standard treatment for hospital-acquired MRSA remains Vancomycin. Although rare, the patient with severe pain or redness that is disproportionately higher than one would expect or an infection that does not improve with first line treatment should lead the surgeon to suspect the possibility of: Necrotizing fasciitis, atypical mycobacterium, herpetic viral infections, or fungal infections.

24.12.9 Bleeding and Hematomas

Most postoperative hematomas occur within the first 24 h when postoperative pain causes an increase in blood pressure or the patient bends over or valsalvas and increases pressure. The Tumescent anesthesia technique has revolutionized cosmetic surgery in many ways. There is a dramatic reduction in bleeding during procedures with this technique which translates into decreased bruising. The literature does not identify a lower rate of hematoma formation after surgery using

tumescent anesthesia versus standard local anesthesia. Reducing the chance of bleeding with surgery begins before the procedure. Uncontrolled hypertension must be corrected. Baker and others have shown that the use of Clonidine preoperatively has lowered the hematoma rate with rhytidectomy. This centrally acting alpha 2 agonist decreases sympathetic out flow and can also cause sedation. It further has been shown to reduce the need for postoperative narcotics [38]. Use of this medication in elderly patients on beta blockers is not recommended. Any history of bleeding problems with prior surgery or within the family should be appropriately investigated. Medications that might affect platelet function or the clotting cascade must be discontinued to allow sufficient time for the return of normal clotting. When performing multiple cosmetic procedures on the same patient it is important to realize that the vasoconstrictive effect of epinephrine will wear off more quickly in the face and neck area as compared to other parts of the body due to the rich blood supply. Because of this a higher concentration of epinephrine is used in the face and neck area. During submentoplasty, the most common area to encounter bleeding is from the anterior jugular veins. Precise suture ligation or cautery performed under direct vision with a very good lighted retractor is critical. When partial submandibular gland resection is performed one can easily develop bleeding from perforators of the submental artery and vein, which are branches of the facial artery and vein. Desperate attempts to control arterial bleeding in this area can increase the risk of injury to the marginal mandibular nerve and lingual nerve. Excellent lighting, exposure and suctioning should facilitate pinpoint cauterization of the vessels. One must always remember to stay calm and simply place gauze packs for pressure to

a

Fig. 24.30 Thermal injury from laser-assisted liposuction. This is a full thickness burn that was treated with local wound care. Avoiding these kinds of injuries requires that the laser fiber be in constant motion, especially when near the dermis

control large areas, so care can be used to isolate each and every significant bleeder. If this is not successful, careful suture ligation should be performed while being mindful of the nearby neural anatomy.

When hematomas occur postoperatively one can consider needle aspiration under local anesthesia if the hematoma is small. Naturally large or rapidly expanding hematomas should be immediately drained surgically. Consider placing a drain at that time even though drains are not used routinely for facial surgery. The literature has not demonstrated that drains decrease the chance of hematoma formation. Close postoperative follow-up in this situation is mandatory. At the time of those postoperative visits one will often see areas of induration in the area where the hematoma was located. This will often respond to external ultrasound and massage. Occasional injections of small doses of Kenalog 10 mg/ml will also help to soften these areas.

24.12.10 Skin Slough

This problem is rare with traditional microcannular liposuction or submentoplasty. Ischemic changes have recently become more common with the use of laser lipolysis. Regardless of the exact wavelength used, too much heat building up below the skin can cause thermal injury. The picture below demonstrates full thickness burn necrosis in a patient who underwent laser-assisted liposuction of the jowls with submentoplasty (Fig. 24.30). The burn likely occurred as a result of not moving the laser fiber continuously and perhaps being too superficial. This type of injury can require local wound care and even skin grafting.

b