Complications of Neck Liposuction and Submentoplasty James Koehler, MD, DDS KEYWORDS
Each year the demand for cosmetic surgery procedures has increased and many surgeons have incorporated these techniques into their practice. The biggest challenge that faces surgeons is obtaining predictable results without complications. As with any surgery, complications occur from time to time. Having the knowledge and skill to deal with these complications is paramount. As long as the surgeon has good rapport with the patient, they are given the opportunity to care properly for these unfavorable results. Many times, patients desiring improved neck and jawline contours are looking for minimally invasive procedures and are not interested in undergoing extensive face-lifting procedures. Realizing the limitations, surgeons may offer their patient such procedures as liposuction and submentoplasty. Even though these procedures are less involved than a face-lift, still many pitfalls can occur that can result in an unfavorable result and a disappointed patient. Proper patient selection and choosing the correct operation are crucial to avoiding these situations. This article focuses on the common complications of neck liposuction and submentoplasty and reviews their management and avoidance.
PATIENT ASSESSMENT AND PROCEDURE SELECTION After a detailed history, the initial assessment should rule out any pathologic processes that may be contributing to a poor neck and jawline, such as thyroid hyperplasia or salivary gland pathology. In the absence of pathology, the skin tone and fatty deposits of the neck should be
evaluated. In general, a younger patient with good skin tone and preplatysmal fat deposits is a better candidate for liposuction. Determining the amount of preplatysmal fat can be difficult. By gently pinching the skin with the fingers one can try to estimate the amount of preplatysmal fat. In the heavy neck patient there is likely a fair amount of fat below the platysma, which cannot be treated with liposuction alone. Patients with subplatysmal fat deposits do not respond well to liposuction alone and are often left with a poor chin-neck angle and submental fullness. Provided the patient has adequate skin tone, a submentoplasty should be considered in these circumstances, because subplatysmal fat can be visualized and resected. Submentoplasty is an excellent procedure for improving neck contour in patients who have platysmal banding, subplatysmal fat deposits, and mild submental cutis laxis without significant jowling. This procedure involves a platysmaplasty and the removal of supraplatysmal and subplatysmal fat through a submental incision. Patient selection is critical to avoid complications. Both liposuction and submentoplasty procedures require that the patient have good skin tone to obtain a smooth result. Patients with significant laxity and poor tone should not be selected for these procedures and the patient should be offered some type of face-lift procedure. Signs of an aging neck include jowling and platysmal banding. Although platysmal banding can be dramatically improved with an aggressive submentoplasty, it must be remembered that the most appropriate procedure for combined jowling and platysmal banding or laxity is often a cervicofacial rhytidectomy with or without a concurrent submentoplasty.
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[email protected] Oral Maxillofacial Surg Clin N Am 21 (2009) 43–52 doi:10.1016/j.coms.2008.10.008 1042-3699/08/$ – see front matter ª 2009 Elsevier Inc. All rights reserved.
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Liposuction Submentoplasty Platysma Laser assisted liposuction Submandibular gland ptosis
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Koehler To provide appropriate patient expectations, several anatomic features should be considered. If the patient has a low hyoid position as determined by neck palpation, a good neck contour may not be achievable even with a flawlessly performed surgery. Recognizing this preoperatively allows the surgeon to discuss the limitations of the procedure or alternatives, such as camouflaging with a chin implant. It is also important to evaluate the presence of large or ptotic submandibular glands preoperatively. If a patient has prominent submandibular glands, the surgeon must either address this with a partial submandibular gland resection or prepare the patient for the possibility of fullness in this area after the procedure.1 Performing partial submandibular gland resection through a submental incision is a difficult procedure and is not recommended for those without significant experience. Complications can be higher with this procedure compared with liposuction and surgical skill and patient selection are extremely important. Liposuction is by far one of the most popular cosmetic procedures for both men and women. Advances in liposuction include the use of tumescent solution, ultrasonic cannulae, power cannulae, and laser-assisted techniques. All surgical techniques require significant training and understanding of the limitations of the procedure. More aggressive tools, such as ultrasonic cannulae, should only be used by those experienced with liposuction. Today the trend is to use small cannulae 1 to 2 mm in diameter. The goal for cervicofacial liposuction is to resculpt the neck to improve the contour, not to remove all the fat.2 Patients are instructed preoperatively that once fat is removed from liposuction, it is expected that the skin shrinks to take on the new contour. It is important to warn the patient that if excess skin laxity develops after the procedure, they may require additional surgical procedures.
TUMESCENT ANESTHESIA Tumescent anesthesia originated in the dermatology literature where safe liposuction could be performed under local anesthesia alone. It was found that using a dilute solution of lidocaine and epinephrine decreased the blood loss during liposuction and provided safety to the technique.3–5 Even though there is minimal blood loss with submental liposuction, tumescent anesthesia distends the tissue plane between the platysma and the skin and facilitates the liposuction procedure.6 Although the rate of absorption of lidocaine and epinephrine in the face is much faster because of the excellent blood supply, toxicity is extremely rare because of the low volume of fluid injected.
Likewise, the potential for drug interactions is also unlikely as compared with large-volume body liposuction. Serial plasma lidocaine levels have been measured when using tumescent anesthesia on the face. In one study, the peak plasma levels averaged 2.7 mg/mL and the highest level found in the series was 3.3 mg/mL. Also, the serum levels normally peaked at 1 hour after administration rather than 12 hours body tumescence.7 Premedication with clonidine has been shown greatly to reduce the incidence of intraoperative and postoperative tachycardia with tumescent local. I typically have the patient place a 0.2-mg clonidine patch on the shoulder the morning of surgery. The patch is removed the next day.
OVERRESECTION OF FAT AND PLATYSMAL BANDS The technique for cervicofacial liposuction has evolved over the years.8–16 Previously, surgeons used large spatulated cannulae to extract as much fat as possible from the neck. The initial results were often good, but over time patients developed a skeletonized appearance of the neck. Once the skin has retracted and fibrosis has occurred, this can be a challenging problem to treat. To avoid this problem it is usually best to use a small 1.5- or 2-mm microliposuction cannula. Small cannulae decrease the likelihood of having uneven or lumpy results. It is important that the cannula opening always be pointed toward the platysma. If the cannula is facing the skin, it can result in gouging of the dermal tissues and cause increased scarring, induration, and palpable skin irregularities. Ultrasonic liposuction cannulae, although available for facial liposuction, are not recommended in this region because the amount of fat is minimal and the risk of thermal injury to dermal tissues is too great unless the surgeon has significant experience with ultrasonic liposuction. Autologous fat transfer may be needed to correct irregularities or overresection of fat. Fat grafting techniques have been extensively described. Many discussions arise as to how the fat should be treated, and this is outside the scope of this article. Keys to success involve the atraumatic harvesting of fat using 10-mL syringes attached to a small-diameter blunt cannula (1–2 mm). The abdomen usually is a good site for fat harvest through a stab incision in the umbilicus. The supranatant fat may be washed and treated and then should be transferred into 1-mL syringes and injected into multiple subdermal tunnels using a fine 16-gauge injection cannula. Some cannulae have a forked tip that allows the surgeon to breakup any subdermal adhesions and facilitate
Neck Liposuction and Submentoplasty placement of the fat. Patients typically swell extensively after fat grafting and should be warned of this preoperatively. Overcorrection with grafting should be done, because not all the fat survives. The predictability of fat transfer is debatable and the patient should understand that several sessions may be required. In some cases, the removal of fat unmasks underlying platysmal banding. If the neck contour is satisfactory, mild cases of platysmal banding can be managed by injection of botulinum toxin A into the areas of banding. Each band may require variable dosing and a typical band requires 20 units botulinum toxin A.17 The dose should be distributed along the band with the injections sites spaced 1.5 cm apart. This needs to be repeated approximately every 4 months and may be used as a palliative treatment until more definitive treatment, such as submentoplasty with excision of platysmal bands or platysmaplasty, is performed. Caution should be taken if treatment involves excision of the platysma muscle. If there is insufficient fat on the skin flaps or the removal is not performed evenly, significant irregularities can occur and are difficult to correct with fat grafting.
Liposuction of the jowls, if performed at all, should be done conservatively. Jowling should be corrected with face-lift techniques and liposuction in this area can create a very unnatural appearance. Placing a small prejowl chin implant is an alternative to liposuctioning jowls in patients unwilling to undergo face-lift surgery. Solid silicone prejowl chin implants do not increase chin projection but do provide some fullness just anterior to the jowls thereby camouflaging the extent if jowling. The prejowl implant may add width to the chin and this should be discussed with the patient before surgery. The so-called ‘‘cobra neck’’ deformity can occur with submentoplasty and usually results from overresection of subplatysmal fat in the midline of the neck. A relative deformity can also occur because of inadequate removal of fat laterally, giving the appearance of a sunken area in the submental region. Even removal of fat is essential to preventing this problem (Fig. 1). Leaving an adequate layer of fat on the skin flaps also helps mask minor irregularities. In patients who have decussation of the platysma at the midline, it may be necessary to release the platysma at the level of
Fig.1. (A) Preoperative view of a 58-year-old woman with submental fullness. (B) The patient underwent submentoplasty but had residual fatty deposits in the right jowl and submental region (arrow). (C) The area was effectively treated with minor liposuction under local anesthesia.
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Koehler the hyoid bone and advance it to the midline to provide a smooth contour to the neck. This is especially true in thinner patients with less fat deposits.
UNDIAGNOSED SUBMANDIBULAR GLAND PTOSIS Recognizing submandibular gland enlargement or ptosis preoperatively is difficult and often overlooked before liposuction or submentoplasty procedures. Ptosis of the submandibular gland can occur with age or the patient simply may have a prominent gland. This is sometimes recognized as a bulge below the mandibular border preoperatively but in many cases is masked by overlying fat and platysma (Fig. 2). Once the neck has been reshaped by liposuction or submentoplasty, the gland may be much more noticeable and a concern for the patient. Preoperative recognition and counseling of the possibility of this is important. After liposuction, the gland may present as a firm noticeable mass in the neck and can occur unilaterally or bilaterally. Treatment of this problem can be difficult. Some surgeons have tried suture resuspension techniques at the time of face-lift surgery with limited success. Another option is partial resection of the superficial portion of the submandibular gland. Superficial resection of the gland can be performed through a submental skin incision approximately 3 cm in length. The technique is difficult and not recommended unless the surgeon already is very adept at doing a submentoplasty procedure. After making the incision a large skin flap is raised and the platysma is exposed. Subplatysmal flaps are elevated using electrocautery and the
gland is usually easily noticeable if it is bulging or ptotic. Blunt dissection with a hemostat helps expose the submandibular gland. It is then grasped with a long forceps and the superficial portion can then be amputated slowly with electrocautery. Caution must be taken to avoid deep transection of the gland while working through a distant and small anterior incision, because bleeding from even a small branch of the facial artery or vein can be difficult to deal with from this limited access. Injury to the marginal mandibular branch is always a concern but unless the surgeon is overly aggressive permanent nerve injury is not common. Closure of the cervical fascia perforation over the residual gland with 2–0 Vicryl can be performed with a single interrupted suture. The closure of fascia over the gland is not absolutely necessary but may decrease the chance of postoperative hematoma, sialoceles, or recurrent gland ptosis. Once again, this procedure is for experienced surgeons and has a definite learning curve.
SIALOCELE Sialoceles, although relatively uncommon (
