Submental Liposuction

25.1 Introduction

Submental liposuction alone, or as an adjunct to a more formal neck lift with platysmaplasty and/or facelift, is a procedure that can result in significant contour improvement in the submental area. Initially performed in the late 1970s via a lateral approach and a larger cannula, it has since evolved into a procedure performed with smaller cannulas and a submental incision [1, 2]. Liposuction of the mandibular border, jowl, and cheek has also been added to improve the contour of the lower face. Subplatysmal fat, while better excised under direct vision, has also been removed via liposuction.

Submental liposuction is traditionally reserved for younger patients with good skin tone, elasticity, skin contraction, and adherence. The goal of such an operation is to achieve the criteria demonstrated in youthful necks. These criteria have been described as: a distinct inferior mandibular border from mentum to angle with no jowl overhang, a visible subhyoid depression, a visible thyroid cartilage bulge, a visible anterior sternocleidomastoid bulge, a submental-sternocleidomastoid line angle of 90° or a cervicomental angle of 105–120° [3]. The chin neck relationship is also considered in the aesthetic rejuvenation of the lower face. Chin augmentation is oftentimes performed in conjunction with submental liposuction. Individuals who either are not candidates for a facelift or do not desire the extended recovery period of a facelift may achieve improved appearance with submental liposuction alone. In these

M. Low

8107, Newport Beach, CA 92658, USA e-mail: drlow@live.com

patients, who are often older in age, midline fullness is the best predictor of a good outcome whereas as thin skin is the best predictor of a poor outcome [4]. The presence of platysmal banding and subplatysmal fat should be noted as these conditions will be inadequately treated by submental liposuction alone.

25.2 Technique

As for all aesthetic plastic surgery procedures, a thorough physical examination of the neck is critical to proper patient selection and the achievement of outstanding results. The examination begins with an assessment of the skin. Crepe paper thin skin is a predictor of a poor outcome unless a concomitant facelift is performed. The presence of multiple, deep horizontal, or oblique creases in the neck predict poor redraping of the skin postoperatively. A snap test demonstrates the tone and elasticity present in the skin. A pinch test revealing an excess amount of skin laxity may dictate an excisional procedure. The apparent cervical skin excess evident after submental liposuction is required for effective contouring of the neck. An assessment of the amount and location of preplatysmal fat is then made. Midline fullness, even more so than age and skin tone, is the best predictor of a good outcome. Generally, a pinch thickness of 1.5–2.0 cm will be evident. Subplatysmal fat is filled with connective tissue and feels firmer than preplatysmal fat. Clenching of the teeth with subsequent contraction of the platysma will help define the presence of preplatysmal fat. The presence of visible platysmal banding with and without animation should be noted. The position of the hyoid-thyroid complex is examined. A low position of the hyoid-thyroid complex often equates to

a less well-defined cervicomental angle, which may limit the achievement of optimal results following submental liposuction. Asymmetries and submaxillary gland fullness are also noted. Standard preoperative photographs including anterior, lateral, and oblique views should be obtained.

Prior to the initiation of the procedure, appropriate landmarks are outlined in the upright sitting position. This is crucial as landmarks change when in the recumbent position. These landmarks include: the mandibular border, the marginal mandibular nerve, the borders of the sternocleidomastoid muscle, and the thyroid cartilage and the hyoid bone. The localized area of fat is also outlined.

The procedure may be performed under general or local anesthesia. Endotracheal tube placement during general anesthesia may limit the ability to appropriately liposuction the area. Generally, submental liposuction can be performed through a well-placed submental crease incision. Retrolobular incisions are used in those cases where extensive fat removal and/ or cross-tunneling is required. A pinch test performed while the cannula is inserted aid in determining the appropriate depth of the cannula. Pretunneling is crucial in this area to determine the appropriate plane of dissection and evacuation. The safe plane is superficial to the platysma muscle. It further aids in the smooth redraping necessary in this area following liposuction. Subdermal suctioning is not recommended as this may result in subdermal vascular plexus injury causing skin loss, surface irregularities, pigmentary changes, and prolonged induration. Small bore (1 –3 mm) Mercedes tip cannulas or spatula cannulas with the holes oriented away from the dermis are used. Liposuction performed with the cannula holes directed toward the dermis has also been described [5]. Hyperextension of the neck is a helpful position for this procedure. A gentle to and fro excursion of the cannula is employed. The cannula is passed more frequently over the area of fat deposition with feathering of the edges beyond the area of maximal deposition. Total volumes removed range from 25 to 100 ml or more depending on the size of the neck and amount of fat. Decreased suction power or hand suction can be employed. Constant use of the pinch test to determine the end point or completion of suctioning is vital. A pinch test of less than 1 cm over the entire treated region is usually achieved. Conservative removal of fat will yield excellent results. Less is more in submental liposuction. Over-liposuctioning of fat in

this area is disastrous as the remaining inadequate submental fat will result in dermis adhering to the platysma causing unsightly irregularities. This complication is difficult if not impossible to correct. Occasionally, contour irregularities and ridging may occur despite uniform fat aspiration and pinch thickness. Fibrous bands passing from the platysma to the dermis are the usual cause and can be divided using a closed neck dissector or sharp scissor dissection. Layered closure of the incision and the application of a compression garment for at least 7 days complete the procedure.

25.3 Discussion

There have been multiple mechanisms postulated for the generally excellent results obtained following submental liposuction [6]. The results obtained may be related to: amount of fat removed, the creation of multiple tunnels, contractile healing of the multiple tunnels, redraping of skin over liposuctioned areas, and/or the inherent elasticity of the skin. It is likely that a combination of factors is involved in the outcome following submental liposuction.

Complications of submental liposuction include: bleeding and hematoma, infection, hypesthesia, skin loss, hyperpigmentation, prolonged induration, marginal mandibular nerve injury, and perforation of the skin, larynx, trachea, or carotid. Aesthetically, overor under-resection is possible as is dimpling and contour irregularities. Skin excess or insufficient redraping is also an outcome that is possible is patients inadequately selected for this procedure.

Skin contraction following liposuction is undoubtedly the rate limiting step to an ideal outcome. Traditional suction-assisted lipectomy of the submental area has been demonstrated to produce excellent results in properly chosen patients [4, 7]. Internal ultrasound-assisted liposuction, external ultrasound-assisted liposuction, and power-assisted liposuction have all been employed in the attempt to improve skin contraction and ultimately the aesthetic result [6].

The recent addition of laser-assisted liposuction has added to the adjunctive technological armamentarium available for liposuction surgeon [8]. Laser-assisted lipolysis uses laser energy via a cannula/fiber combination to deliver light energy with subsequent transformation to heat within the adipocyte ultimately causing

cell lysis and the liberation of lipids into the extracellular space. The liquefied fat is then usually extracted or aspirated by traditional means. Additional effects of the application of laser energy include: coagulation of vessels within the adipose tissue, coagulation of adipose and dermal collagen, and a reorganization of the reticular dermis with neocollagenesis in the deep dermis and dermal fat junction. These effects clinically translate into less intraoperative blood loss, less postoperative ecchymosis and swelling, more rapid recovery following the procedure, and enhanced skin tightening and skin redraping due to the neocollagenesis. It may also minimize surgeon fatigue while aspirating the fat. The effects on skin tightening are particularly useful in contouring of the submental region. A recent study has elegantly demonstrated objective skin tightening following laser-assisted liposuction using a 1,064 nm wavelength laser [8]. There is also some suggestion that using laser-assisted lipolysis may result in smoother contours with an ultimate decrease in the revision rate [8].

At the time of this writing, multiple differing wavelengths for laser-assisted lipolysis have been FDA approved. These include Nd:Yag and diode lasers of the following wavelengths: 924, 975, 980, 1,064, 1,320, 1,444 nm, and 1,470 nm. The laser energy is

applied via 600–1,000 Pm optical fibers. Sequencing in laser-assisted lipolysis procedures consists of standard tumescence of the target area followed by laser energy application and then completion aspiration. Some users apply laser energy subsequent to aspiration while others have attempted lasing in revision cases without aspiration. The goal in these cases is to take advantage of the skin tightening effects. The targeted efficacy of each wavelength has been touted and supported by data from each of the respective laserassisted lipolysis device manufacturers. The most efficacious wavelength in laser-assisted lipolysis is hotly debated and remains to be determined. A recent peerreviewed article has demonstrated the usefulness of a 1,064 nm wavelength in submental region [9].

25.4 Conclusions

Submental liposuction alone, in carefully selected patients or in conjunction with an additional platysmaplasty or excisional procedure, has been shown to be effective in addressing submental lipodystrophy with improved contours in the lower facial aesthetic subunit (Figs. 25.1–25.4). Careful patient selection,

assessment, and judicious defatting are the keys to success. New technology has been introduced and applied adjunctively while performing submental liposuction. Laser-assisted lipolysis has shown particular promise in minimizing bleeding and downtime while improving the tightening, contouring, and redraping of skin following liposuction.

References

1.Illouz YG. The origins of lipolysis. In: Hetter GP, editor. Lipoplasty: the theory and practice of blunt suction lipectomy. New York: Lippincott Williams & Wilkins; 1984. p. 25.

2.Hetter GP. Lipoplasty of the face and neck. In: Hetter GP, editor. Lipoplasty: the theory and practice of blunt suction lipectomy. New York: Lippincott Williams & Wilkins; 1984. p. 249.

3.Ellenbogen R, Karlin JV. Visual criteria for success in restoring the youthful neck. Plast Reconstr Surg. 1980;66(6): 826–37.

4.Gryskiewicz JM. Submental suction-assisted lipectomy without platysmaplasty: pushing the (skin) envelope to avoid a face lift for unsuitable candidates. Plast Reconstr Surg. 2003;112(5):1393–405.

5.Goodstein WA. Superficial liposculpture of the face and neck. Plast Reconstr Surg. 1996;98(6):988–96.

6.Rohrich RJ, Rios JL, Smith PD, Gutowski KA. Neck rejuvenation revisited. Plast Reconstr Surg. 2006;118(5):1251–63.

7.Courtiss E. Suction lipectomy: a retrospective analysis of 100 patients. Plast Reconstr Surg. 1984;73:780.

8.Goldman A, Gotkin RH. Laser assisted liposuction. Clin Plast Surg. 2009;36(2):241–53.

9.Goldman A. Submental Nd:Yag laser-assisted liposuction. Lasers Surg Med. 2006;38(3):181–4.