Your patient comes into the office with a complaint: “My neck bothers me. It is making me feel old.”
What do you do?
Liposuction of the neck can be used to obtain an improved neck/chin profile. This applies to patients with good skin elasticity whose primary defect is localized fat excess in the neck and submental region.
In patients with mild loose skin and not much fat, liposuction also can be used successfully.
How does that work if there is not much fat?
There are two aspects to a successful liposuction of the neck.
The first—and most obvious—is that the excess fat is mechanically suctioned and lipocytes are removed from the body.
Just as important but often overlooked by both patient and physician: In the process of removing fat with the liposuction cannula, the overlying skin is separated from the underlying muscle and superficial musculoaponeurotic system (SMAS).
Immediately following liposuction of the neck, the superficial skin is repositioned and taped snuggly.
This allows for the skin and underlying SMAS to heal with fibrotic scar tissue, resulting in a tighter neck.
SKIN ELASTICITY IS KEY
Ideal candidates for neck liposuction should have sufficient skin elasticity. This allows a smooth and uniform redraping of the superficial tissues over the newly defined neck.
The ability of the skin to contract after liposuction is often remarkably good.
Even older patients may obtain significant improvement of their neck with liposuction alone.
If the patient has excessive loose skin in addition to excess fat, a facelift and/or necklift procedure may be required to achieve the best results.
In 1921, the chief of surgery at the Coucicout Hospital in Paris attempted to improve the contour of a well-known ballerina’s knees by removing excess adipose tissue.
The procedure was performed through a small incision using a uterine curette.
Unfortunately, a fulminant infection arose, and because it was before the days of antibiotics, the patient needed a lower-leg amputation.
This catastrophe generated widespread negative reactions toward blind lipoextraction, suspending further investigations for nearly 50 years.
In 1972, Joseph Schrudde of Germany introduced a new closed procedure: lipexheresis.
During this procedure, fat was excised with a sharp uterine curette via a small buttonhole skin incision. Suction was not used.
In addition, many post-treatment problems ensued, such as seromas and irregular contours.
In the mid-1970s, Swiss surgeon Ulrich Kesselring, Italian surgeon Giorgio Fischer, and French surgeon Yves Fournier first introduced liposuction.
Each surgeon decided to attach a suction apparatus to their own uniquely designed curettage instruments.
In the early 1980s, French surgeon Yves-Gerard Illouz clearly established liposuction as a substantial surgical modality for body contouring.
He developed techniques that are recognized as the foundation of modern-day liposuction. Fournier further improved Illouz’ technique.
Most recently, liposuction and laser-based devices have been combined in the increasingly popular Smartlipo and Vaser treatments.
|This 34-year-old male desired more definition of the neck and jawline. The treatment called for liposuction of the neck only. Note the improvement of the cervico-mental angle.
NECK LIPO TECHNIQUE
The patient is usually taken to an outpatient operating room.
The procedure can be performed under either local anesthesia with or without intravenous sedation, or under general anesthesia.
The type of anesthesia should be determined preoperatively by the surgeon and patient, depending upon the individual circumstances.
Also during the preop meeting, all of the details of the procedure—as well as realistic expectations of the results of the procedure—should have been discussed.
The procedure can be performed alone or in combination with other surgical procedures.
Local infiltrative anesthesia is used for vasoconstriction and hydro-dissection, regardless of whether intravenous sedation or general anesthesia is used.
A tumescent technique in the neck, though not frequently used in my practice, consists of varied mixtures of 0.5% lidocaine with 1:200,000 epinephrine and hypotonic saline.
|This 26-year-old female had “pooch” under her neck since her early teens, which particularly bothered her when she flexed her neck. The treatment called for liposuction to the neck only.
Anesthesia in the nontumescent technique is accomplished with 1% lidocaine with 1:100,000 epinephrine.
The face and neck are prepped and draped in a sterile fashion.
The patient’s neck should have been marked with a skin marker in the preop area, with the patient in a sitting position.
The areas of excess fat and skin, as well as the inferior margin of the mandible, are marked.
The 0.5 cm submental incision is placed 1 mm posterior to the natural submental skin crease.
During the healing process, the incision should migrate into the natural crease.
A #15 blade is used to create the midline submental incision.
A small tenotomy scissors is used to create short pockets just under the skin and over the subcutaneous fat, inferiorly and laterally.
|A 47-year-old male wanted more definition of the neck; the answer was liposuction of the neck.
Pretunneling is done prior to active suctioning.
Without any suction, a small spatulated single lumen 2-mm, 3-mm, or 4-mm liposuction cannula is passed into the submental incision. It is used to create tunnels in a radial fashion, laterally to the sternocleidomastoid muscles and inferiorly to the thyroid cartilage.
The plane of dissection remains just under the skin and over the fat.
Once these tunnels have been created, the cannula is connected to approximately 25-mm Hg suction pressure and liposuction is begun.
Suction pressure should be off every time the cannula is removed from or inserted into the incision, so as to avoid the potential of injury to the incision site.
The lumen opening of the cannula should always be turned toward the fat/muscle and not toward the dermal surface, in order to avoid injury to the subdermal plexus and subsequent postop irregularities.
|This 48-year-old male desired more definition of the neck, for which he received liposuction of the neck and a medium-sized Mittleman prejowl-chin implant. He shaved his beard for the first time in years after the procedure.
Fat is removed via the cannula throughout the pretunneled area in the same radial direction.
The dominant hand is used to pass the cannula while the nondominant hand guides the cannula, directs fat into the lumen, and maintains the proper dissection plane.
Care must be taken to maintain a superficial plane so as to avoid injury to blood vessels and nerves.
The end of suctioning has been reached when mostly blood and no fat is in the suction tubing.
Two additional 0.5-cm incisions are made—one behind each earlobe hidden in the infralobular crease, vertically oriented.
Again, use a small scissors to create a subdermal tunnel. The small cannula is again used to connect with the previously created tunnels.
The criss-crossing from these different directions creates a much-improved result than when compared to a decision to use only the submental incision.
ALTERNATIVES TO NECK LIPOSUCTION & FUTURE TRENDS
A facelift/necklift may surgically correct the aged neck.
In men, a direct excision of midline fat and excess skin with a W-plasty closure will improve the neck.
The latest hot buzz at the aesthetic surgical meetings is represented by products such as Vaser Liposelection, laser lipolysis, and Smartlipo.
These devices and procedures can be used to dissolve fat cells upon contact with ultrasonic or laser-based energy.
With only local anesthetic and mild sedation, the fat is melted and then gently massaged and suctioned out via tiny cannulas.
These treatments will break down fat in precise, selective areas.
Overall, though, the future of facial plastic surgery is rapidly moving toward noninvasive treatments.
Radiofrequency-based devices, such as Velashape and Accent XL, are becoming more popular with patients who do not want surgery. These types of devices provide controlled heat therapy for noninvasive, nonablative body shaping and skin tightening.
Ultrashape is a promising device developed in Israel but not yet released in the United States.
Reportedly, it melts fat by using external high-frequency ultrasound “paddles,” in which the ultrasonic energy passes through the patient’s epidermis and dermis to rupture the underlying fat cells.
Fractionated carbon dioxide (CO2)-based lasers, such as Deep FX and Fraxel Re:pair, are proving to be effective at tightening lax skin of the neck.
Mechanical liposuction of the neck is the least invasive of the surgical treatment options for the neck ,and will remain a mainstay of the plastic surgeon’s treatment options.
In most cases, the cannula should be kept below the margin of the mandible. If suctioning is performed above the mandible, exercise great caution to avoid injury to the marginal mandibular branch of the facial nerve.
Prior to completing the procedure, the surface contour of the neck should be examined carefully. Any dimpling or asymmetries should be corrected.
Dimpling is corrected by releasing the subcutaneous residual fat attachments. Obvious platysmal bands can be plicated prior to closure.
In some cases, a chin, prejowl, or chin/prejowl implant is beneficial to redefine the chin and jawline.
If implants are necessary, I prefer using products made by Mittelman Plastic Surgery Center.
In some patients, the neck-jawline improves dramatically from using these implants alone.
The incisions are closed with 6-0 Prolene in an interrupted fashion.
Dressing the neck is very critical to the result. The entire neck should be painted with Ferndale Laboratories’ Mastisol Liquid Adhesive.
Two-inch French stretch tape is then used in an overlapping horizontal taping, taking care to pull the skin in an upward-lateral vector. The tape is left in place for 5 to 7 days.
Patients are instructed to keep their neck-chin angle as close to 90° as possible, to sleep on their back, and to remain elevated on two or three pillows.
Swelling and bruising from the procedure take approximately 2 weeks to resolve.
In some cases, edema may last longer. As the postop edema resolves, subtle surface irregularities may appear; however, they are usually short-lived and resolve spontaneously.
Short-term numbness may take a few weeks to resolve. Postop discomfort is minimal in the isolated procedure.
Patients may return to normal activities after 1 week.
Complications from neck liposuction are, fortunately, infrequent and usually minor in nature.
See also “Rejuvenate the Neck” by Bernard A. Shuster, MD, FACS in the November 2006 issue of PSP.
Infections are rare, reported in 0.15% of cases. Prophylactic antibiotics is a common practice.
Hematomas, seromas, and prolonged edema occur in less than 1% of cases.
Small hematomas or seromas respond well to needle aspiration and pressure. Permanent injuries to the marginal mandibular branch of the facial nerve or the greater auricular nerve have occurred, but they are extremely rare.
When paresis, or paralysis, does occur, it is almost always transient and resolves within weeks.
Michael A. Persky, MD, FACS, has practiced facial plastic and reconstructive surgery in Encino, Calif, since 1985. He is board certified by both the American Academy of Facial Plastic and Reconstructive Surgery and the American Academy of Otolaryngology-Head and Neck Surgery. He can be reached at (818) 501-3223.