fat contouring in the face and neck

FAT CONTOURING IN THE FACE AND NECK

GERALD H. PITMAN, MD

Fat removal via closed aspiration or open excision under direct vision through limited incisions can produce significant and beneficial featural change in the face and neck. These minimally invasive procedures are not substitutes for face and neck lift in older patients with lax facial tissues. Patients selected for this surgery should have sufficient skin elasticity so that the skin envelope will smoothly reduce to the decreased volume. Copyright �9 1996 by W.B. Saunders Company

KEY WORDS: liposuction, buccal fat pad, neck and face

The advent of liposuction for body contouring in the late 1970s was followed in the early 1980s by application of liposuction to the face and neck. 1-7 The ability to remove fat through minimal incisions prompted a renewed interest in face and neck fat removal as a method of favorably altering contour.

ANATOMY

Neck

Superficial fat in the submental and submandibular areas is divided into two compartments (Fig 1):

�9 the space deep to the skin and superficial to the platysma;

�9 the space deep to the platysma but superficial to the superficial layer of the deep investing fascia.

Fat also exists deep to the superficial layer of the deep investing fascia. In the submental area, this fat lies between the anterior bellies of the left and right digastric muscles.

The fat superficial to the platysma muscle is easily accessible via liposuction through stab incisions. The fat deep to the platysma but superficial to the deep fascia is also accessible via liposuction under direct vision through a 3- to 4-cm transverse submental incision. The deep fat beneath the superficial layer of investing fascia should be left undisturbed, because its removal will create an unaes- thetic submental hollow.

Face

Fat in the face is also divided into a superficial and deep compartment (Fig 2). The superficial fat lies between the

From the Department of Plastic Surgery at the Manhattan Eye, Ear & Throat Hospital, and the Institute of Reconstructive Plastic Surgery at the New York University School of Medicine, New York, NY.

Address reprint requests to Gerald H. Pitman, MD, 170 East 73rd St, New York, NY 10021.

Copyright �9 1996 by W.B. Saunders Company 1071-0949/96/0302 -000255.00/0

skin and the superficial musculoaponeurotic system (SMAS). The deep fat consists of the buccal fat pad which in the cheek lies in the space deep to the SMAS and superficial to the buccopharyngeal fascia and buccinator muscle. The superficial fat is accessible via liposuction through stab incisions in the facial skin, nasal vestibule, and vermillion of the oral commissure. Portions of the buccal fat pad can be removed most easily under direct vision through a short intraoral incision.

TREATMENT OF THE NECK

L i p o s u c t i o n A l o n e

Pat ient select ion. Although there is great individual varia- tion in skin elasticity and the ability of neck skin to contract to a reduced volume, younger patients usually get better results. Carefully selected patients in their late forties may achieve satisfactory changes, but consistently excellent results are usually seen only in patients in their twenties

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Fig 1. A coronal section through the submentum shows the two layers of superficial fat external to the deep investing fascia and the deep fat internal to the deep investing fascia between the digastric muscle bellies. Reprinted with permission from Pitman GH: Liposuction and Aesthetic Surgery. St Louis, MO, Quality Medical Publishing, 1993.

94 Operative Techniques in Plastic and Reconstructive Surgery,, Vol 3, No 2 (May), 1996: pp 94-105

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Q Fig 2. (A) An interdental cross-section shows the locations of the superficial cheek fat and the deep buccal fat pad. (B) Buccal branches of the facial nerve run just beneath the SMAS along the superficial aspect of the buccal fat pad. The facial vein courses through the anterior portion of the buccal fat pad in the cheek. Reprinted with permission from Pitman GH: Liposuction and Aesthetic Surgery. St Louis, MO, Quality Medical Publishing, 1993.

and thirties. The preoperative presence of vertical skin wrinkling indicates a reduced ability of the skin to contract and precludes an optimal result.

The sine qua non of liposuction in the neck is the presence of fat verified by the pinch test, which should be at least 1.5 cm between the thumb and index finger. Better results are obtained in patients with pinch thicknesses in excess of 2 cm. Aspirated volumes usually range from 25 to 200 cc.

Surgical technique. The areas of maximal fat deposition are marked with the patient in an upright position. Access incisions in the submental and bilateral retrolobular creases are also marked (Fig 3).

Liposuction begins 10 minutes after infiltration with local anesthesia. Adequate anesthesia and hemostasis are

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Fig 3. Typical markings for cervical liposuction. Reprinted with permission from Pitman GH: Liposuction and Aesthetic Surgery. St Louis, MO, Quality Medical Publishing, 1993.

achieved with minimal amounts of lidocaine 0.25% with epinephrine 1:400,000. I do not use a tumescent technique for this area because a large volume infiltration obscures fine detail.

I use 2.4- and 3.0-ram Mercedes cannulas. Before begin- ning suction from the retrolobular incisions, the skin is separated from the underlying sternocleidomastoid fascia to which it is intimately adherent (Fig 4A). Gentle spreading in a horizontal direction with a curved Stevens scissors will safely establish the plane of dissection before using the cannula.

Suction is carried out just beneath the surface of the skin with more time spent in areas of greatest fat deposition, usually the submentum. The neck is suctioned from two access incisions to avoid waviness and create a smooth surface contour (Fig 4B).

The end point of suction is a visually apparent, reduced contour and a pinch test of 1.0 to 1.5 cm. Some fat must be left in the subcutaneous space, and conservatism will be rewarded with consistently satisfactory results. Excessive resection will result in the undersurface of the dermis becoming adherent to the platysma.

After completion of suction, the stab wounds are not sutured, because they heal with negligible scars. An adhesive-backed, quarter-inch-thick foam sponge (Reston, 3M, Minneapolis, MN) is placed over the operative area up to the lower cheek and ears to provide compression and support (Fig 5). The sponge is removed 48 hours after surgery, and the patient is provided with an elastic chin strap, which is worn at night for 3 weeks. Bruising is generally minimal.

Results. Cervical liposuction in a youthful patient will produce a predictably first-rate result (Fig 6).

A 35-year old woman will have less skin elasticity, but

FAT CONTOURING IN THE FACE AND NECK 95

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Fig 4. (A) Separation of skin from sternocleidomastoid fascia using Stevens scissors through retrolobular incision. Separation should extend beyond the anterior edge of the sternocleidomastoid muscle. Establishing the plane of suction in this manner avoids misdirection of the cannula and possible injury to the marginal mandibular nerve. (B) Criss-cross pattern of suctioning creates smooth surface contour. Reprinted with permission from Pitman GH: Liposuction and Aesthetic Surgery. St Louis, MO, Quality Medical Publishing, 1993.

will usually achieve a satisfactory result from liposuction (Fig 7).

Liposuction With Subplatysma Fat Removal and Anterior Platysma Plication

Patient selection. Patients with very voluminous cervical fat collections and/or lax platysma muscle may require subplatysma fat removal and/or platysma-tightening procedures to achieve optimal results from fat removal in the neck. These additional procedures require slightly larger submental and, in some cases, retrolobular incisions, but the scarring is still minimal, and periauricular scars can be avoided. Men, because of their bulkier musculo-skeletal conformation, frequently require subplatysma fat removal and platysma tightening to achieve optimal results.

Surgical technique. Marking is identical to that for liposuction alone. After preliminary liposuction, the submental stab incision is opened 3 to 4 cm, and the skin and fat are elevated off of the underlying platysma using a Mayo or similar face-lift type scissors (Fig 8). A lighted fiber-optic retractor permits extensive freeing of the skin under direct vision. The retractor is also useful for obtaining complete hemostasis.

The median platysma decussation is excised, exposing the subplatysma component of the superficial fat (Fig 9). If excessive, the central portion of this fat is excised with scissors (Fig 10). Lateral extensions of the fat can be removed by liposuction with a 2.4- or 3.0-mm Mercedes cannula placed under direct vision (Fig 11). The cannula should hug the undersurface of the platysma muscle and be directed below the mandibular border to avoid injury to the marginal mandibular branch of the facial nerve.

Following completion of fat removal, the median left and right platysma borders are sutured together in the midline with a running 3-0 absorbable suture of poligle-

caprone 25 (Monocryl, Ethicon, Somerville, NJ). The suture extends from the submental incision towards the sternal notch as far as indicated by the patient's anatomy (Fig 12). In some patients, more than one layer of sutures is used to thoroughly tighten and imbricate an excessively lax muscle.

Anterior platysma tightening draws the overlying skin towards the midline and creates lateral dimpling, which is relieved by additional undermining to free and redrape the skin (Fig 13). The retrolobular incisions may be enlarged, and undermining carried out from behind the ear lobe as well.

Jackson-Pratt suction drains are placed into the depths of the wound and led out the retrolobular incisions. After wound closure with 5-0 nylon skin sutures, an adhesive- foam sponge dressing is applied as for liposuction of the neck. Drains are removed in 24 hours.

Results. A 41-year-old man with a small lipoma in the right supraplatysma submandibular space and excess fat

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Fig 5. Adhesive-backed foam sponge cut to size and fitted to neck. Reprinted with permission. 8

96 GERALD H. PITMAN

Fig 6. Before (A,C) and 6 months after cervical liposuction (B,D) in a 17-year-old girl.

FAT CONTOURING IN THE FACE AND NECK 9 7

Fig 7. Before (A,C) and 8 years after cervical liposuction (B,D) in a 35-year-old woman.

throughout the supraplatysma space was treated with closed liposuction of the supraplatysma space followed by direct excision of the lipoma through a 4-cm transverse submental incision. The platysma was plicated in the

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Fig 8. Undermining submental fat and skin to expose platysma. Reprinted with permission from Pitman GH: Liposuc- tion and Aesthetic Surgery. St Louis, MO, Quality Medical Publishing, 1993.

midline, and the cervical skin was undermined from submental and retrolobular incisions (Fig 14).

A 46-year old man had a large subplatysma lipoma removed through a 4-cm transverse submental incision. The platysma was plicated and imbricated in the midline, and skin redraping was carried out from submental and retrolobular incisions (Fig 15).

Both of the above patients underwent preoperative imaging studies to verify the diagnosis of lipoma and to ascertain the full extent of the tumor before surgery and its exact anatomic location relative to the platysma.

TREATMENT OF THE FACE

Patient Selection

Surgical fat removal from the face is performed much less frequently than fat removal from the neck. In the neck a clean, sharply defined cervicomandibular angle and a relatively straight line from the mentum to the hyoid are admired features of movie stars and fashion models. In the face, however, a paucity of fat is less desirable. Full, softly rounded facial features are signs of youth and good health, whereas a thin, gaunt face is universally recognized as an unwanted accompaniment of age and ill health.

Patients selected for facial fat removal either have genetically disproportionate facial fat deposition at normal

98 GERALD H. PITMAN

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Fig 9. Excision of the median platysma decussation. Re- printed with permission from Pitman GH: Liposuction and Aesthetic Surgery. St Louis, MO, Quality Medical Publishing, 1993.

weight or are overweight and have been unable to achieve weight reduction. Fat removal should be conservative in all cases, but particularly so in the overweight patient who may subsequently lose additional facial fat through dieting.

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Fig 10. Excision of central sub-platysma fat. Reprinted with permission from Pitman GH: Liposuction and Aesthetic Sur- gery. St Louis, MO, Quality Medical Publishing, 1993.

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Fig 11. Placement of cannula to suction lateral subplatysma fat. Note marginal mandibular and branch of facial nerve. Reprinted with permission from Pitman GH: Liposuction and Aesthetic Surgery. St Louis, MO, Quality Medical Publishing, 1993.

Surgical Techn ique

The areas of excessive fullness in the cheeks are marked with the patient upright. These areas begin below the zygoma and maxilla and extend in an inferior direction to the mandibular body. Laterally, the area begins over the parotid gland and extends as far medially as the nasolabial and labiomental folds (Fig 16). Local anesthesia with or without sedation is sufficient for most patients.

The excessive superficial fat is aspirated by liposuction. Only very small amounts of fat are removed, because surface irregularities are easy to create with excessive resections. Volumes removed are usually too small to measure. Mercedes cannulas 1.5 and 1.8 mm in diameter are inserted through stab wounds in the retrolobular crease and nasal vestibule (Fig 17). The oral commissures are also satisfactory sites for access incisions.

After aspiration of the superficial fat in the cheek, a portion of the buccal fat pad is excised under direct vision via an intraoral approach. Removal of 3 to 5 cc of buccal fat, in combination with aspiration of small amounts of superficial fat, usually removes enough volume to create a desirable change in facial contour.

A 1.5-cm mucosal incision is made parallel to the gingivobuccal sulcus and halfway between the sulcus and the parotid duct papilla (Fig 18). This incision is usually centered on the second maxillary molar. The fibers of the buccinator muscle directly subjacent to the mucosa are spread with the points of a Stevens scissors exposing the buccopharyngeal fascia, which is pierced with the scissors and spread (Fig 19). Gentle external hand pressure on the cheek causes the fat to pout through the intraoral incision where it is grasped with forceps and gently teased out (Fig 20).

The fat is excised with careful attention to cauterizing all vessels. Only the fat that protrudes through the incision

FAT CONTOURING IN THE FACE AND NECK 9 9

should be removed. Blind attempts to pull fat from the depths of the wound can result in injury to the facial vein or buccal branches of the facial nerve. The intraoral wound is closed in one layer with interrupted 4-0 chronic sutures,

The patient is instructed to drink clear liquids for the remainder of the day and resume a soft diet the following day. No dressing is required.

Results

A 28-year-old, moderately overweight woman was unable to change her facial appearance with dieting (Fig 21, see page 105). Her mother and grandmother had similarly rounded features. I treated her face with liposuction of

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Fig 12. Midline plication and imbrication of platysma to tighten superficial musculature of anterior neck. In some patients, this maneuver will also increase cervicomandibular definition. Used with permission from Pitman GH: Liposuc- tion and Aesthetic Surgery. St Louis, MO, Quality Medical Publishing, 1993.

Fig 13. (A and B) Undermining from submental and retrolobular incisions to permit skin redraping after anterior platysma plication. Reprinted with permission from Pitman GH: Lipo- suction and Aesthetic Surgery. St Louis, MO, Quality Medical Publishing, 1993.

the superficial compartment and buccal fat pad excision through an intraoral approach. I also performed simultaneous liposuction of the neck. She is shown before and 3 months after treatment.

CONCLUSION

Fat removal via closed aspiration or open excision under direct vision through limited incisions can produce significant and beneficial featural change in the face and neck. These minimally invasive procedures are not substitutes for face and neck lift in older patients with lax facial tissues. Patients selected for this surgery should have sufficient skin elasticity so that the skin envelope will smoothly reduce to the decreased volume.

100 GERALD H. PITMAN

Fig 14. Before (A,C) and 6 months after (B,D) liposuction of neck, removal of supraplatysma lipoma, platysma tightening, and skin redraping in 41-year-old man. Reprinted with permission from Pitman GH: Liposuction and Aesthetic Surgery. St Louis, MO, Quality Medical Publishing, 1993,


Fig 15. Before (A,C) and 8 months after (B,D) removal of subplatysma lipoma, platysma tightening, and skin redraping in 46-year-old man. Reprinted with permission from Pitman GH: Liposuction and Aesthetic Surgery. St Louis, MO, Quality Medical Publishing, 1993.


Fig 16. Dotted lines indicate areas of cheek fullness to be treated by fat removal. Reprinted with permission from Pitman GH: Liposuction and Aesthetic Surgery. St Louis, MO, Quality Medical Publishing, 1993.

Fig 17. Facial liposuction with 1.5- and 1.8-mm Mercedes cannulas. Reprinted with permission from Pitman GH: Lipo- suction and Aesthetic Surgery. St Louis, MO, Quality Medical Publishing, 1993.

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Fig 18. Location of intraoral incision for partial buccal fat pad removal. Positive identification of parotid duct papilla is essential to avoid injury to this important structure. Re- printed with permission from Pitman GH: Liposuction and Aesthetic Surgery. St Louis, MO, Quality Medical Publishing, 1993.


Fig 19. Spreading buccinator muscle and buccopharyngeal fascia to expose buccal fat pad. Reprinted with permission from Pitman GH: Liposuction and Aesthetic Surgery. St Louis, MO, Quality Medical Publishing, 1993.

REFERENCES

1. IllouzY-G: Body contouringbylipolysis.A5-year experience with over 3000 cases. Plast Reconstr Surg 72:591-597, 1983

2. Teimourian B: Face and neck suction-assisted lipectomy associated with rhytidectomy. Plast Reconstr 72:627-633, 1983

3. Avelar J: Fat suction of the submental and submandibular regions. Aesthet Plast Surg 9:257-263, 1985

4. Lewis CM: Lipoplasty of the neck. Plast Reconstr Surg 76:248-257, 1985 5. Topia A, Ferreira B, Eng R: Liposuction in cervical rejuvenation.

Aesthet Plast Surg 11:95-100, 1987

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Fig 20. Gentle external pressure applied to extrude fat into oral cavity. Reprinted with permission from Pitman GH: Liposuction and Aesthetic Surgery. St Louis, MO, Quality Medical Publishing, 1993.

6. Pitman GH: Suction lipectomy of the face and body: Precision and refinement, in Riley WB: (ed): Plastic Surgery Educational Foundation Instructional Courses. St Louis, MO, Mosby, 1988, pp 71-106

7. Pitman GH: Face and neck contouring by fat removal, in Courtiss EH (ed): Male Aesthetic Surgery, St Louis, MO, Mosby-Year Book, 1991, pp 304-315

8. Pitman GH: Liposuction & Aesthetic Surgery, St Louis, MO, Quality Medical Publishing, 1993, pp 111-167


Fig 21. Before (A,C) and 3 months after (B,D) liposuction of superficial facial fat combined with buccal fat pad excision via an intraoral approach. Simultaneous liposuction of the neck was also performed. Reprinted with permission from Pitman GH: Liposuction and Aesthetic Surgery. St Louis, MO, Quality Medical Publishing, 1993.


fat contouring in the face and neck

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