Complications of NeckLiposuction andSubmentoplasty

James Koehler, MD, DDS

KEYWORDS� Liposuction � Submentoplasty � Platysma� Laser assisted liposuction � Submandibular gland ptosis

Each year the demand for cosmetic surgery pro-cedures has increased and many surgeons haveincorporated these techniques into their practice.The biggest challenge that faces surgeons is ob-taining predictable results without complications.As with any surgery, complications occur fromtime to time. Having the knowledge and skill todeal with these complications is paramount. Aslong as the surgeon has good rapport with the pa-tient, they are given the opportunity to care prop-erly for these unfavorable results.

Many times, patients desiring improved neckand jawline contours are looking for minimally in-vasive procedures and are not interested in under-going extensive face-lifting procedures. Realizingthe limitations, surgeons may offer their patientsuch procedures as liposuction and submento-plasty. Even though these procedures are less in-volved than a face-lift, still many pitfalls can occurthat can result in an unfavorable result and a disap-pointed patient. Proper patient selection andchoosing the correct operation are crucial toavoiding these situations. This article focuses onthe common complications of neck liposuctionand submentoplasty and reviews their manage-ment and avoidance.

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PATIENTASSESSMENTAND PROCEDURESELECTION

After a detailed history, the initial assessmentshould rule out any pathologic processes thatmay be contributing to a poor neck and jawline,such as thyroid hyperplasia or salivary gland pa-thology. In the absence of pathology, the skintone and fatty deposits of the neck should be

Tulsa Surgical Arts, 7322 East 91st Street, Tulsa, OK 7413E-mail address: james@tulsasurgicalarts.com

Oral Maxillofacial Surg Clin N Am 21 (2009) 43–52doi:10.1016/j.coms.2008.10.0081042-3699/08/$ – see front matter ª 2009 Elsevier Inc. All

evaluated. In general, a younger patient with goodskin tone and preplatysmal fat deposits is a bettercandidate for liposuction. Determining the amountof preplatysmal fat can be difficult. By gently pinch-ing the skin with the fingers one can try to estimatethe amount of preplatysmal fat. In the heavy neckpatient there is likely a fair amount of fat below theplatysma, which cannot be treated with liposuctionalone. Patients with subplatysmal fat deposits donot respond well to liposuction alone and are oftenleft with a poor chin-neck angle and submental full-ness. Provided the patient has adequate skin tone,a submentoplasty should be considered in thesecircumstances, because subplatysmal fat can bevisualized and resected. Submentoplasty is an ex-cellent procedure for improving neck contour in pa-tients who have platysmal banding, subplatysmalfat deposits, and mild submental cutis laxis withoutsignificant jowling.Thisprocedure involvesaplatys-maplasty and the removal of supraplatysmal andsubplatysmal fat through a submental incision. Pa-tient selection is critical to avoid complications.Both liposuction and submentoplasty proceduresrequire that the patient have good skin tone to ob-tain a smooth result. Patients with significant laxityand poor tone should not be selected for these pro-cedures and the patient should be offered sometype of face-lift procedure.

Signs of an aging neck include jowling and pla-tysmal banding. Although platysmal banding canbe dramatically improved with an aggressive sub-mentoplasty, it must be remembered that the mostappropriate procedure for combined jowling andplatysmal banding or laxity is often a cervicofacialrhytidectomy with or without a concurrentsubmentoplasty.

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To provide appropriate patient expectations,several anatomic features should be considered.If the patient has a low hyoid position as deter-mined by neck palpation, a good neck contourmay not be achievable even with a flawlessly per-formed surgery. Recognizing this preoperativelyallows the surgeon to discuss the limitations ofthe procedure or alternatives, such as camouflag-ing with a chin implant. It is also important to eval-uate the presence of large or ptotic submandibularglands preoperatively. If a patient has prominentsubmandibular glands, the surgeon must eitheraddress this with a partial submandibular gland re-section or prepare the patient for the possibility offullness in this area after the procedure.1 Perform-ing partial submandibular gland resection througha submental incision is a difficult procedure and isnot recommended for those without significantexperience. Complications can be higher with thisprocedure compared with liposuction and surgicalskill and patient selection are extremely important.

Liposuction is by far one of the most popularcosmetic procedures for both men and women.Advances in liposuction include the use of tumes-cent solution, ultrasonic cannulae, power cannu-lae, and laser-assisted techniques. All surgicaltechniques require significant training and under-standing of the limitations of the procedure. Moreaggressive tools, such as ultrasonic cannulae,should only be used by those experienced withliposuction. Today the trend is to use small can-nulae 1 to 2 mm in diameter. The goal for cervico-facial liposuction is to resculpt the neck to improvethe contour, not to remove all the fat.2 Patients areinstructed preoperatively that once fat is removedfrom liposuction, it is expected that the skinshrinks to take on the new contour. It is importantto warn the patient that if excess skin laxity de-velops after the procedure, they may require addi-tional surgical procedures.

TUMESCENTANESTHESIA

Tumescent anesthesia originated in the dermatol-ogy literature where safe liposuction could be per-formed under local anesthesia alone. It was foundthat using a dilute solution of lidocaine and epi-nephrine decreased the blood loss during liposuc-tion and provided safety to the technique.3–5 Eventhough there is minimal blood loss with submentalliposuction, tumescent anesthesia distends thetissue plane between the platysma and the skinand facilitates the liposuction procedure.6

Although the rate of absorption of lidocaine andepinephrine in the face is much faster because ofthe excellent blood supply, toxicity is extremelyrare because of the low volume of fluid injected.

Likewise, the potential for drug interactions isalso unlikely as compared with large-volumebody liposuction. Serial plasma lidocaine levelshave been measured when using tumescent anes-thesia on the face. In one study, the peak plasmalevels averaged 2.7 mg/mL and the highest levelfound in the series was 3.3 mg/mL. Also, the serumlevels normally peaked at 1 hour after administra-tion rather than 12 hours body tumescence.7 Pre-medication with clonidine has been shown greatlyto reduce the incidence of intraoperative and post-operative tachycardia with tumescent local. I typi-cally have the patient place a 0.2-mg clonidinepatch on the shoulder the morning of surgery.The patch is removed the next day.

OVERRESECTION OF FATAND PLATYSMAL BANDS

The technique for cervicofacial liposuction hasevolved over the years.8–16 Previously, surgeonsused large spatulated cannulae to extract asmuch fat as possible from the neck. The initial re-sults were often good, but over time patients de-veloped a skeletonized appearance of the neck.Once the skin has retracted and fibrosis has oc-curred, this can be a challenging problem to treat.

To avoid this problem it is usually best to usea small 1.5- or 2-mm microliposuction cannula.Small cannulae decrease the likelihood of havinguneven or lumpy results. It is important that thecannula opening always be pointed toward theplatysma. If the cannula is facing the skin, it canresult in gouging of the dermal tissues and causeincreased scarring, induration, and palpable skinirregularities. Ultrasonic liposuction cannulae, al-though available for facial liposuction, are not rec-ommended in this region because the amount offat is minimal and the risk of thermal injury to der-mal tissues is too great unless the surgeon has sig-nificant experience with ultrasonic liposuction.

Autologous fat transfer may be needed to cor-rect irregularities or overresection of fat. Fat graft-ing techniques have been extensively described.Many discussions arise as to how the fat shouldbe treated, and this is outside the scope of thisarticle. Keys to success involve the atraumaticharvesting of fat using 10-mL syringes attachedto a small-diameter blunt cannula (1–2 mm). Theabdomen usually is a good site for fat harvestthrough a stab incision in the umbilicus. The supra-natant fat may be washed and treated and thenshould be transferred into 1-mL syringes and in-jected into multiple subdermal tunnels usinga fine 16-gauge injection cannula. Some cannulaehave a forked tip that allows the surgeon to break-up any subdermal adhesions and facilitate

Neck Liposuction and Submentoplasty 45

placement of the fat. Patients typically swell exten-sively after fat grafting and should be warned ofthis preoperatively. Overcorrection with graftingshould be done, because not all the fat survives.The predictability of fat transfer is debatable andthe patient should understand that several ses-sions may be required.

In some cases, the removal of fat unmasks un-derlying platysmal banding. If the neck contour issatisfactory, mild cases of platysmal banding canbe managed by injection of botulinum toxin Ainto the areas of banding. Each band may requirevariable dosing and a typical band requires 20units botulinum toxin A.17 The dose should be dis-tributed along the band with the injections sitesspaced 1.5 cm apart. This needs to be repeatedapproximately every 4 months and may be usedas a palliative treatment until more definitive treat-ment, such as submentoplasty with excision ofplatysmal bands or platysmaplasty, is performed.Caution should be taken if treatment involves exci-sion of the platysma muscle. If there is insufficientfat on the skin flaps or the removal is not per-formed evenly, significant irregularities can occurand are difficult to correct with fat grafting.

Fig.1. (A) Preoperative view of a 58-year-old woman with stoplasty but had residual fatty deposits in the right jowl atively treated with minor liposuction under local anesthes

Liposuction of the jowls, if performed at all,should be done conservatively. Jowling shouldbe corrected with face-lift techniques and liposuc-tion in this area can create a very unnatural ap-pearance. Placing a small prejowl chin implant isan alternative to liposuctioning jowls in patientsunwilling to undergo face-lift surgery. Solid sili-cone prejowl chin implants do not increase chinprojection but do provide some fullness just ante-rior to the jowls thereby camouflaging the extent ifjowling. The prejowl implant may add width to thechin and this should be discussed with the patientbefore surgery.

The so-called ‘‘cobra neck’’ deformity can occurwith submentoplasty and usually results fromoverresection of subplatysmal fat in the midlineof the neck. A relative deformity can also occurbecause of inadequate removal of fat laterally, giv-ing the appearance of a sunken area in the sub-mental region. Even removal of fat is essential topreventing this problem (Fig. 1). Leaving an ade-quate layer of fat on the skin flaps also helpsmask minor irregularities. In patients who have de-cussation of the platysma at the midline, it may benecessary to release the platysma at the level of

ubmental fullness. (B) The patient underwent submen-nd submental region (arrow). (C) The area was effec-ia.

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the hyoid bone and advance it to the midline toprovide a smooth contour to the neck. This is es-pecially true in thinner patients with less fatdeposits.

UNDIAGNOSED SUBMANDIBULARGLAND PTOSIS

Recognizing submandibular gland enlargement orptosis preoperatively is difficult and often over-looked before liposuction or submentoplasty pro-cedures. Ptosis of the submandibular gland canoccur with age or the patient simply may havea prominent gland. This is sometimes recognizedas a bulge below the mandibular border preopera-tively but in many cases is masked by overlying fatand platysma (Fig. 2). Once the neck has been re-shaped by liposuction or submentoplasty, thegland may be much more noticeable and a concernfor the patient. Preoperative recognition and coun-seling of the possibility of this is important. Afterliposuction, the gland may present as a firm no-ticeable mass in the neck and can occur unilater-ally or bilaterally. Treatment of this problem canbe difficult. Some surgeons have tried sutureresuspension techniques at the time of face-liftsurgery with limited success. Another option ispartial resection of the superficial portion of thesubmandibular gland.

Superficial resection of the gland can be per-formed through a submental skin incision approx-imately 3 cm in length. The technique is difficultand not recommended unless the surgeon alreadyis very adept at doing a submentoplasty proce-dure. After making the incision a large skin flap israised and the platysma is exposed. Subplatysmalflaps are elevated using electrocautery and the

Fig. 2. (A) Preoperative view of a 55-year-old woman whoneck liposuction. (B) The postoperative picture shows the

gland is usually easily noticeable if it is bulging orptotic. Blunt dissection with a hemostat helps ex-pose the submandibular gland. It is then graspedwith a long forceps and the superficial portioncan then be amputated slowly with electrocautery.Caution must be taken to avoid deep transectionof the gland while working through a distant andsmall anterior incision, because bleeding fromeven a small branch of the facial artery or veincan be difficult to deal with from this limited ac-cess. Injury to the marginal mandibular branch isalways a concern but unless the surgeon is overlyaggressive permanent nerve injury is not common.Closure of the cervical fascia perforation over theresidual gland with 2–0 Vicryl can be performedwith a single interrupted suture. The closure of fas-cia over the gland is not absolutely necessary butmay decrease the chance of postoperative hema-toma, sialoceles, or recurrent gland ptosis. Onceagain, this procedure is for experienced surgeonsand has a definite learning curve.

SIALOCELE

Sialoceles, although relatively uncommon (<0.5%),are certainly more frequent after a partial subman-dibular gland resection with a submentoplasty.Treatment may involve serial needle aspirationand pressure dressings. If there is doubt in distin-guishing the fluid from a seroma, the fluid can besent to test for the presence of amylase. Medicaltreatment for a sialocele includes the use of an anti-sialogogue or the injection of botulinum toxin A intothe submandibular gland.18,19 Sialoceles veryrarely require surgical management unless the vol-ume does not continue to decrease or if the overly-ing skin integrity is compromised.

did not want a facelift but instead underwent isolateduntreated submandibular gland ptosis (arrow).

Neck Liposuction and Submentoplasty 47

NERVE INJURY

Liposuction of the jowls and neck can result intransient weakness of the marginal mandibularbranch of the facial nerve. Permanent injury is un-likely with microcannular liposuction unless theoperator is overzealous or uses a cannula tip de-sign that could potentially cut the nerve. Injury tothe marginal mandibular nerve is much more com-mon with a submentoplasty compared withliposuction. The nerve is at greatest risk if subpla-tysmal flaps are elevated to access the subman-dibular gland. In my experience, marginalmandibular nerve injury occurs less than 1% ofthe time. Fortunately, all of these resolved withoutany intervention. The incidence of facial nerve in-jury in face-lift surgery is reported from 0.5% to1.7%.20 As long as the surgeon does not suspecttransection of the nerve, the only thing to do iswait for resolution. In the event of unilateral neuro-praxia, the surgeon can inject 15 units of botulinumtoxin to the depressors of the lip on the unaffectedside to provide symmetry. It is wise to wait 4 to 6weeks before doing this because function mayreturn when swelling subsides.

Fig. 3. (A) Preoperative view of a 55-year-old man desiringsubmentoplasty with laser-assisted liposuction of the jowfrom overzealous laser liposuction of the jowls. (C) The pomary closure of the wound.

SKIN SLOUGH

Traditional microcannular liposuction of the neckand jowls is unlikely to result in skin loss; however,use of ultrasonic or laser-assisted liposuction cancreate this problem (Fig. 3). The purported advan-tage of ultrasonic or laser liposuction is that theheating of the underside of the dermis results in in-creased collagen formation and better skin retrac-tion following liposuction. Ultrasonic liposuction iswell suited for larger areas on the body where dis-ruption of the fat cells by cavitation can increasethe efficiency of fat removal. In the neck the fat isnot as abundant and it is much easier to overheatthe port site or the areas being liposuctionedresulting in a thermal burn. In body liposuction,skin necrosis from internal ultrasonic liposuctionhas been reported to be as high as 10%.21

Laser liposuction using yttrium-aluminum-gar-net laser technology has recently become popular.The lasers are marketed as providing better skinretraction with less bleeding or bruising andshorter recovery times. For small deposits of fatthe laser-assisted liposuction techniques can behelpful. The expense of the equipment limits the

an isolated neck procedure. (B) The patient underwentls and subsequently sustained full-thickness necrosisstoperative picture shows the result after delayed pri-

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use to those who perform a significant amount ofliposuction in their practices. As is true of all lasers,there is a learning curve and higher power settingscan create burns. The injuries can range frommoderate erythema and pigment changes in theskin to full-thickness necrosis. Management isthe same for any burn, including local woundcare, skin grafting, or delayed primary closure.

BLEEDING AND HEMATOMAS

Using a tumescent technique, the likelihood of he-matomas after facial liposuction is rare. In theevent that a hematoma occurs early after surgery,the area can be anesthetized and a liposuction mi-crocannula can be inserted to evacuate it. Com-pression dressings and ice may help preventrecurrence. Use of external ultrasound may helpwith discomfort and speed the resolution ofinduration.

The most common area to encounter bleedingduring submentoplasty is from the anterior jugularveins in the midline of the neck and can be simplymanaged by suture ligation. If partial submandibu-lar resection is performed it is possible to enco-unter the facial artery and vein. Controllinghemorrhage from the facial vessels from the sub-mandibular incision can be extremely difficult. Ifuncontrolled bleeding in this area occurs, the sur-geon may need to access the area directly over thebleeding in the submandibular region.

Small hematoma in face-lift surgery is reportedto occur at an incidence of less than 15%.22 Thehallmark for expanding hematomas requiring sur-gical drainage is pain uncontrolled by pain medi-cation. Large hematomas in submentoplasty arenot common but could occur. My practice hasa hematoma incidence for submentoplasty lessthan 3%. Surgical evacuation of any large hemato-mas and placement of a drain is the usual treat-ment. Small hematomas can sometimes beaspirated by a large-bore needle under local anes-thesia in the office. In my experience, the use oftumescent anesthesia seems to minimize the inci-dence of hematomas in submentoplasty, althoughthe literature seems to indicate that there is nolower rate of hematoma formation by using it.6

Drains are not typically used in submentoplastyand a light compression dressing is used for 24hours. After that, the patient wears an elastichead wrap for 2 weeks.

SEROMA

Raising a large skin flap or extensive underminingfrom liposuction can also result in the formation ofa seroma. Blood plasma accumulation in the dead

space requires aspiration or the patient can de-velop altered skin retraction and fibrosis in thearea. Seromas are reported to occur at a rate ofless than 3% with facial liposuction.22 Serial nee-dle aspiration and compression dressings gener-ally take care of the problem.

POSTINFLAMMATORY HYPERPIGMENTATION

Patients with Fitzpatrick skin type III or greater aremore prone to development of hyperpigmentationafter liposuction. The hyperpigmentation usuallyresolves without any intervention, but it may take6 months or more. The patient may apply hydro-quinone 4% or kojic acid creams to the affectedareas to help speed the resolution.

INFECTION

Infection is a rare occurrence in both liposuctionand submentoplasty. Appropriate perioperativeantibiotics and good surgical technique preventmost infections. Standard culture and sensitivitiesdetermine antibiotic therapy if infection arises. Themost common organisms are streptococcus andstaphylococcus introduced from the skin flora.The surgeon should also consider the possibilityof methicillin-resistant Staphylococcus aureus be-cause more and more cases are being reported.Community-acquired methicillin-resistant S au-reus tends to be sensitive to fluoroquinolonesand trimethoprim-sulfamethoxazole; however,health care associated methicillin-resistant S au-reus tends to have multidrug resistance and cul-ture and sensitivities direct antibiotic therapy.

Necrotizing fasciitis is extremely rare bacterialinfection but is possible following any surgical pro-cedure. The most common form involves group Ab-hemolytic streptococci, although polymicrobialforms are possible. The hallmarks of this are signif-icant pain uncontrolled by medication and rapidlyprogressive erythema, bronzing of skin, and bullaeformation. Treatment involves aggressive surgicaldebridement, hospitalization, and intravenous an-tibiotics. Hyperbaric oxygen and intravenous Igtherapy are considered experimental treatment atthis time.23

SCARRING

Scarring and poor skin retraction is most com-monly an unfortunate consequence of poor patientselection or poor surgical technique. If the surgeondoes not leave a sufficient amount of fat evenlydistributed on the skin flaps in submentoplastythe skin may not redrape smoothly. If a hematomaor seroma forms and is not treated, significantfibrosis resulting in irregularities can occur.

Neck Liposuction and Submentoplasty 49

SKIN REDUNDANCY

Skin redundancy is usually the result of performingliposuction or a submentoplasty on a patient withpoor skin elasticity. Typically, male patients areunwilling to undergo traditional face-lifts and arelooking for less invasive ways to improve theirneck contour. In some cases, these patients arewilling to accept some skin redundancy froma less invasive approach. Generally, if there isskin excess, it tends to bunch in the midline(Fig. 4). The treatments include performing a formalface-lift or direct excision with a z-plasty (Fig. 5).24

Once again, some men would rather have a scarunder the chin and on the neck than have the inci-sions of a face-lift. It is important to use a z-plastytechnique to avoid linear contracture and scarband formation.

Fig. 4. (A) Preoperative view of a 65-year-old man with poolift and elected for submentoplasty alone. (B) Postoperativof the neck. (C) Submental view of the skin bunching in thave a z-plasty in the midline of the neck rather than a trerative result after a z-plasty.

CHRONIC PAIN

Chronic pain is generally not seen with facial lipo-suction but can occur after submentoplasty in rarecases. After platysmaplasty the patient may reporttightness in the neck and pain on swallowing. Thisis usually from suturing the muscle down to the hy-oid fascia. This usually resolves within a couple ofmonths. The use of medications, such as neuro-ntin, Elavil, and Lyrica, may be helpful for the man-agement of chronic pain.25 In severe cases thesurgeon may need to release the corset suture.

PREVENTION OF COMPLICATIONSWITH CERVICOFACIAL LIPOSUCTION

The patient should be marked before surgery witha permanent marker in an upright position to note

r skin tone and skin laxity who declined having a face-ely the patient developed skin bunching in the midlinehe midline before z-plasty. (D) The patient elected toaditional facelift. The final picture depicts the postop-

Fig. 5. (A) The black ellipse and lines depicts the skinexcision and incisions for a z-plasty for correction ofmidline skin excess in patients who do not wish tohave traditional facelift surgery and are willing to ac-cept a midline neck scar. (B) Diagram showing the skinclosure of the z-plasty. The z-plasty can be performedon both the platysma and skin but should be done intwo separate layers. In cases of poorly defined platys-ma, the muscle may be excised.

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the areas requiring the greatest amount of liposuc-tion. Once tumescent anesthesia is infiltrated itcan be difficult to note the areas of greatestfullness.

After complete skin preparation, the lower faceand submental region are infiltrated with tumes-cent anesthesia using a 22-gauge spinal needleconnected to a Wells Johnson Klein pump. I typi-cally mix 30 mL of 2% lidocaine (600 mg) with1.5 mL of 1:1000 epinephrine (1.5 mg) into 500 mLof normal saline. This then makes a 0.12% lido-caine with 1:333,333 epinephrine. Approximately150 to 200 mL of the solution should be injectedin the lower face and neck just superficial to theSMAS and the platysma. Injection at deeper levelsmay injure nerves or vascular structures. If the in-jection is done too superficially, a peau d’orangeappearance of the skin may be noted. This ap-pearance should be avoided. There are reportsof skin slough in face-lifting that is attributed to

superficial injection of tumescent solution in areasof skin undermining. Approximately 150 mL of tu-mescent solution is used in the submental region.

The skin is then reprepared and the patient isdraped for the procedure. It is best to wait approx-imately 15 to 20 minutes after injecting the solutionbefore beginning liposuction. Stab incisions arefirst made with a #11 scalpel blade in the submen-tal region, and just posterior to the pinna of the earbilaterally.

A small 2-mm microcannula should be moved ina smooth in and out motion and each time the can-nula is pushed in it should enter a new location. Ifthe cannula is kept in the same area for multiplepasses, irregularities develop that can be difficultto correct. The dominant hand holds the cannulaand the nondominant hand should always beheld gently over the skin to feel the depth of thecannula tip. The holes for the cannula should notbe directed toward the dermis because this candisturb the subdermal plexus and result in scarringand irregularities. Additionally, the surgeon shouldfrequently stop to feel the skin to ensure even re-moval of fat. In the neck, the cannula tip shouldnot be directed below the platysma. If removal ofsubplatysmal fat is indicated, it should be donesurgically because excessive bleeding and nerveinjury can result if this is performed blindly.

When performing submental liposuction it is im-portant not to bring the liposuction cannula abovethe inferior border of the mandible from the sub-mental incision. Doing this can place the facialnerve at risk. It is better to access the jowls withthe liposuction cannula from the incisions belowthe pinna of the ear. It is important to understandthat jowling is primarily a problem with descentof tissues with age and not an area of lipohypertro-phy. Conservative liposuction in the area of thejowls can be beneficial but to address the problemproperly the patient should have a lower face-lift.Overly aggressive liposuction of the jowl regioncan result in irregularities and facial nerveweakness.

PREVENTION OF COMPLICATIONSWITH SUBMENTOPLASTY

There have been many techniques described tomanage the neck in a submentoplasty.15,26–33

The techniques to be described are how the authortypically performs this operation. The technique isvaried based on the patient’s anatomy. If there isat least fair skin tone and no platysmal banding,this patient may benefit from liposuction alone. Ifthere is any platysmal banding, then platysma-plasty is needed.

Neck Liposuction and Submentoplasty 51

First, tumescent anesthesia is used to insufflateapproximately 150 mL for an average-size neck.The typical mixture used is 500 mL of normal sa-line, 30 mL of lidocaine 2%, and 1.5 mg of epi-nephrine. A 2- to 3-cm submental incision is thenmade in the natural submental crease. If the pa-tient has a low hyoid position and a chin implantis planned, then the incision is made posterior tothe submental crease. This way the incision doesnot become visible, because the chin implant re-sults in the incision appearing more anterior. Thedissection is carried down to the level of the pla-tysma with a needle tip point cautery.

It is not recommended to perform liposuctionfirst when doing a platysmaplasty because it is es-sential to maintain an even thickness of superficialfat attached to the dermis. When the skin is re-draped there is less chance of an uneven appear-ance and skin rippling. Face-lift scissors are usedto undermine the skin, leaving an even layer ofsubdermal fat. The dissection is carried inferiorlyas far as the lower border of the thyroid cartilageand laterally to the posterior border of the mandi-ble.34 Wide skin undermining is necessary to allowproper skin redraping after treatment of the deeptissues has been addressed. Inadequate skinundermining leads to bunching after midline plica-tion of the platysma.

A flat spatulated cannula can then be used to per-form liposuction on the fat overlying the platysmaunder direct vision. A lighted Aufricht retractor im-proves visualization through the small submentalincision. Any excess submental fat is then re-sected. A Kelly clamp or large hemostat is placedin the midline to hold the platysma and fat whilea needle tip cautery or scissors is used to resectit. It is at this point when the anterior jugular veinsmay be encountered. Proper hemostasis must beachieved, otherwise it is very difficult to completethe operation properly and there is a greater chanceof postoperative hematoma.

After resecting the midline fat, the anterior bor-ders of the platysma and the hyoid bone are iden-tified. The platysma is then backcut beginning atthe level of the hyoid bone. The backcut is carriedback an average of 5 to 7 cm with the cut stayingparallel with the inferior border of the mandible andwell below the inferior extent of the submandibulargland. When making this incision through platys-ma care should be taken not to injure the facialvessels or nerve. The platysma is undermined su-perior to the area backcut. If submandibular glandptosis or gland enlargement is recognized, I oftenmanage this by resecting the superficial portionof the gland with the needle point cautery. Thisprocedure is difficult to do and is not recommen-ded to the novice. Bleeding can be encountered,

which is difficult to control from such a small inci-sion with poor access.

After mobilizing the platysma bilaterally, a corsetplatysmaplasty is then performed. To do this, I usea running 2–0 vicryl suture. The inferior platysmaedges are plicated at the midline to the fasciaover the hyoid bone. If a chin implant is to beused to camouflage a poor cervicomental anglerelated to low hyoid position, it is placed at thistime. Dissection is carried to the periosteum ofthe mandible in the midline. A subperiostealpocket is then created at the lower border of themandible. A solid silicone implant is then placedinto this pocket. It is secured to the periosteumof the inferior border of the mandible with a single4–0 vicryl suture. After ensuring strict hemostasis,the skin is then closed with 4–0 monocryl deep and5–0 plain gut suture on the skin.

A dressing is then placed using Reston foam1563L (3M Medical-Surgical, St. Paul, Minnesota)and a Coban (3M Medical-Surgical, St. Paul, Min-nesota) head wrap. This is worn for 24 hours.When the patient returns the next day postopera-tive, the wrap is removed and the patient then wearsa compression garment, such as a face-lift bra. Thisis to be worn as much as possible, day and nightduring the first week. After 1 week, the patient isto wear the garment at night only for 2 more weeks.

SUMMARY

Poor neck contour is a frequent complaint of pa-tients. Often the most appropriate procedure isa cervicofacial rhytidectomy; however, there areinstances where a less aggressive and perhapsminimally invasive procedure can provide goodesthetic results. The patient with isolated submen-tal fat deposits with good skin tone and minimalplatysmal laxity may benefit from liposuctionalone. Even patients who refuse a face-lift andhave significant platysmal banding and laxity canhave dramatic improvement with submentoplastyalone. Naturally, patients must be informed thatthey may require additional procedures if theseisolated techniques are not completely effectiveto treat their problem. Limitations aside, isolatedneck liposuction with or without associated sub-mentoplasty can be a superb minimally invasivecosmetic procedure. The appropriate patient ap-preciates the improved neck appearance coupledwith a decreased downtime as compared with tra-ditional neck or face-lift techniques.

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