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LIPOSUCTION 101 Liposuction Textbook

Chapter 35:
Chin, Cheeks, and Jowls

Tumescent liposuction is the technique of choice for removing subcutaneous fat in the submental chin and jowl areas. The ideal candidate is the patient who has realistic expectations and who will be satisfied with the results achievable by liposuction.

For many patients with suboptimal skin elasticity, liposuction can achieve gratifying results. Older patients, especially males, are pleased with the ability of their skin to retract and appear sufficiently smooth. Liposuction is particularly appealing to patients who do not want the prolonged recovery time, the scarring, and the risk of complications associated with a facelift.

Two-Stage Tumescent Facelift

Because of the scars associated with facelifts, most male patients prefer tumescent liposuction of the chin, cheek, and jowls (CCJ) over the traditional facelift.

In many women, tumescent liposuction of the CCJ can produce better cosmetic results than a facelift. Female patients also often prefer tumescent liposuction over a facelift because of the following:

  1. Microcannular liposuction involves fewer risks of disfiguring scars.
  2. Tumescent anesthesia eliminates the dangers of systemic anesthesia.
  3. Patients have more rapid recovery.
  4. Tumescent facelifts typically provide a more natural and “less surgical” appearance (Figure 35-1).

Tumescent liposuction with delayed skin resurfacing is often chosen over a facelift by older women with significant subcutaneous fat in the face and neck and marked solar elastosis and aging of the skin. The sequential two-stage cosmetic surgical procedure consists of the following:

  1. Tumescent liposuction of the CCJ, with platysma muscle plication
  2. At a later date, full-face carbon dioxide (CO2) laser resurfacing using tumescent local anesthesia (Figure 35-2).

This approach can yield results that are much superior to a facelift alone (Figures 35-3 and 35-4).

Among younger women who have good skin elasticity, liposuction without ancillary procedures can also produce dramatic improvement and is much simpler than a facelift.

Some women may prefer a facelift because they have minimal subcutaneous fat below the chin but excessively wrinkled, redundant neck skin.

Anatomic Considerations

The phrase “liposuction of the face and neck” is somewhat misleading. To be more specific, liposuction in this general area involves the submental (under chin) area, the jowls, and a small area of the cheeks. Because optimal results do not necessarily require liposuction of the neck caudal to the nuchal crease, or the thyroid cartilage, this procedure is referred to as “liposuction of the chin, cheek, and jowls (CCJ).”

The submentum includes the area bounded proximally by the mandibular margin and submental crease and distally by the nuchal crease. The jowl represents a small focal accumulation of fat overlying the midportion of the mandibular ramus, which usually extends and tapers distally onto the submental area. Jowl fat is anatomically distinct and unrelated to the buccal fat pad.

Surface Anatomy

The appearance of jowl fat is a sign of wisdom and maturity (advancing age). The jowls are an important anatomic feature for the cosmetic surgeon. As a source of concern for women and men of a certain age, prominent jowls rank with wrinkles and platysmal bands as unwanted facial features.

Wrinkles. Facial wrinkles are not significantly improved by liposuction. Several other techniques, however, including dermabrasion, laser resurfacing, and chemical peeling, may successfully treat facial wrinkles.

Tumescent dermabrasion is probably the most successful technique for eliminating the perioral rhytids on the lips. Dermabrasion, however, depends more on clinical experience and surgical skills than do laser resurfacing or chemical peeling.

Platysmal Bands. The platysma muscle bands highly visible on the anterior neck often contain a large quantity of fat. Tumescent liposuction may improve the appearance of platysmal bands to some degree. A submental crease incision with platysma muscle plication, however, provides much greater cosmetic improvement (see later discussion).

Redundant Skin. Excessive redundant skin on the anterior neck is treated by either (1) a facelift with subcutaneous musculoaponeurotic system (SMAS) plication or (2) submental skin excision and platysma muscle plication. Newer laser methods or chemical peels might prove successful for treating wrinkles on the neck and submental area. The risk of scarring discourages most cosmetic surgeons from aggressive resurfacing on the neck.

In certain patients, liposuction combined with facial skin resurfacing and platysma muscle plication can achieve results that are superior to the traditional facelift.

Gross Anatomy of Subcutaneous Fat

The principal fat compartment of the CCJ is the midline submental fat. These fat pads, together with the fat of the droopy jowls, are the main targets for liposuction of the CCJ.

Tumescent Advantages. Tumescent infiltration improves the safety of liposuction in these areas. Careful and gentle tumescent infiltration elevates the subcutaneous fat away from the deeper neurovascular structures below the platysma muscle. Precise tumescent infiltration and cautious microcannular technique reduce the risk of postliposuction skin irregularities on the jowls and cheeks.

Excessive liposuction can leave permanent depressions and lipotrops that cannot be repaired by fat transplantation. An overaggressive technique that intentionally targets the apical fat along the deep surface of the dermis can result in adhesions, scarring contractures, areas of necrosis, and dyschromia. Overenthusiastic liposuction of the medial nasolabial cheeks can easily become excessive liposuction.

Conservative liposuction of the cheeks using the smallest cannulas can achieve gratifying results. Similarly, minimal liposuction along the inferior aspect of the mandible can produce a more youthful, well-defined jaw line. The surgeon must be cautious to avoid injury to vascular structures that are subjacent to the thin platysmal muscles in this area.

Tumescent local anesthesia of the CCJ has proved to be safe provided that the infiltration is done with care and precision. To my knowledge, no reported cases of laryngeal edema have been associated with the subcutaneous infiltration of large volumes of dilute lidocaine and epinephrine into the CCJ and neck.

Larynx. The larynx is essentially a protective valve at the upper end of the respiratory passage.1 It consists of a framework of articulating cartilages connected by ligaments. The important laryngeal cartilages are the thyroid, cricoid, arytenoid, and the epiglottis. The laryngeal ligaments and muscles connect the laryngeal cartilages.

The fasciae that invest the cartilages, ligaments, and muscles act as a barrier that protects the larynx from subcutaneous soft tissue edema. From the perspective of tumescent liposuction, these sheets of fascial tissue prevent tumescent anesthetic solution from diffusing into the larynx and causing laryngeal edema or paralysis of laryngeal nerves.

Risk Factors. Liposuction of the CCJ should be confined to the subcutaneous fat superficial to the platysma muscles. The important motor nerves and blood vessels of the face and neck are deep to the platysma muscles. To avoid risk of injury to the thyroid gland, liposuction should not be extended too far distally beyond the cricoid cartilage.

The tumescent technique is not intended for thyroid suction or inadvertent thyroidectomy. Hemorrhage into the thyroid gland can result in laryngeal edema. Hemorrhage into the neck, deep to the investing fascia of the larynx, may put external pressure on the trachea and cause airway obstruction. Trauma to and obstruction of venous or lymphatic vessels deep to the platysma may cause laryngeal edema.

It is especially important not to attempt liposuction of the CCJ if the patient may have recently taken aspirin, nonsteroidal antiinflammatory drugs (NSAIDs), or other agents that might impair hemostasis and predispose to local hematoma and direct pressure on the trachea.

Intraoperative Positioning

Patient positioning is important for comfort and optimal access to the treatment area. Preferably the patient is supine or comfortably recumbent, with the back and knees slightly flexed and the neck moderately extended. Too much or too little extension of the neck will make it more difficult to palpate accurately the deep interface between the submental fat and the subjacent muscle fascia.

The patient’s hands and arms should be lightly restrained by a towel wrapped around the arm and tucked under the patient. This prevents the patient from possibly contaminating the surgical field (Figure 35-5).

Anesthetic Infiltration

Tumescent infiltration of the neck is accomplished by first infiltrating along the deepest planes of subcutaneous fat, then more superficially. In an awake and fully alert patient, infiltration is accomplished with minimal discomfort by initially injecting small blebs of tumescent anesthetic solution into the dermis at the intended sites of 1.0-mm adits, made with a skin biopsy punch, or 2-mm to 3-mm microincisions. The microincisions can be made with a small scalpel blade (e.g., no. 11) or 16-gauge Nokor needle (Becton-Dickinson).

The tumescent local anesthetic solution for CCJ liposuction, with or without platysma plication, typically consists of 1.5 g lidocaine, 1.5 mg epinephrine, and 10 mEq sodium bicarbonate in 1 L of normal saline. The liposuction usually requires 250 to 350 ml of tumescent anesthetic solution.

The goal is to achieve optimal anesthesia and hemostasis. Moderate tumescence is preferable; extreme or massive tumescence is unnecessary and possibly unsafe.

Accurate infiltration is essential for depositing the anesthetic solution as close as possible to the deep margin of the submental fat pad. Precision infiltration is optimal using a 25-gauge, 5-cm (2-inch)–long needle on a 12-ml syringe. Using a hand-held syringe for the initial phase of the infiltration allows fine control of the rate and volume of infiltration.

After the initial deep infiltration, one can continue using syringes. Alternatively, one can use a electric motor–powered peristaltic pump, with either a 25-gauge pediatric spinal needle or a 20-gauge spinal needle, to complete the tumescent infiltration.

In a thin patient who has only a small or localized distribution of CCJ fat, the entire infiltration is best accomplished by syringe. With skill and experience, infiltration of the CCJ can be accomplished painlessly, without systemic sedation or analgesia.

Cannula Size

Liposuction of the submental area was introduced in the 1980s, when liposuction was usually accomplished by general anesthesia. With early liposuction, “facial” cannulas were large and often flattened or spatula shaped. The width of different cannulas ranged from 3 to 10 mm.

Incisions sites for cannula insertion in the CCJ area vary with cannula size. To accommodate a cannula with minimal cutaneous friction, the incisions must be slightly longer than the width of the largest cannula. For large cannulas the location and number of incisions are limited by the requirement that the scars be well hidden.

With the advent of tumescent liposuction the use of microcannulas became practical. Surgeons began to appreciate that microcannulas allow greater finesse, more predictable results, less inflammation, and more rapid healing, with fewer complications.

Large Cannulas. For liposuction of the submental chin and neck, some surgeons continue to use large cannulas with one or three relatively large incisions. This traditional approach involves one of the following:

  1. Single midline incision in the submental crease
  2. Combination of midline incision and bilateral subauricular incisions that allow some crisscross tunneling in the submental fat

The use of large cannulas necessitates that the incision be closed by sutures. This discourages drainage and prolongs postoperative elastic compression for 2 weeks or more. Using large cannulas precludes finesse and the ability to treat small areas of the cheeks.

The preference for using large cannulas for CCJ liposuction is partly a result of surgical tradition. Surgical training is justifiably conservative and discourages extreme deviations from fundamental techniques. Once a technique is mastered, surgeons are disinclined to modify the procedure dramatically. Nevertheless, careful conservatism must not discount the possibility of innovation and improvement.

Microcannulas. Microcannulas produce excellent aesthetic results. I prefer microcannulas with an inside diameter (ID) of 2.2 mm or less (12 gauge or smaller). The microcannulas that I use to treat the CCJ are the 16-gauge and 14-gauge HK Finesse and 20-, 18-, and 16-gauge Capistrano.

Adits and microincisions do not require sutures, so drainage is unimpeded and rapid. Postoperative elastic compression of the CCJ is only necessary for 18 to 36 hours. Microincisions simply disappear rapidly without hyperpigmentation.

With 16-gauge and 14-gauge cannulas the surgeon can use microincisions that are 2 to 3 mm in length. A 1.0-mm adit or a 2-mm to 3-mm linear incision that is not excessively traumatized by a cannula will disappear within days. The risk of postinflammatory hyperpigmentation of the face is no greater than that encountered with a typical nick from a razor while shaving.

Location of Adits

The preferred pattern for using microcannulas for liposuction of the CCJ usually involves three to 10 adits or microincisions. Multiple adits permit the extensive use of crisscrossing patterns for the microcannula paths, which allows the smoothest results.

Three 1.0-mm adits spaced equally along the submental crease are sufficient for patients requiring liposuction confined to the submental area and limited by the mandibular rami. The typical patient in this category is a young, thin female with only a few milliliters of fat under the chin.

The average patient might require five or six adit incisions, which include the three equally spaced adits in the submental crease. Two bilaterally symmetric incisions are placed beneath the mandibular rim between the angle of the jaw and the jowl area, near the anterior border of the masseter muscle.

An obese patient may require an additional pair of symmetric incisions at approximately the level of the hyoid bone and lateral to the border of the thyroid cartilage (Figure 35-6).

Surgical Technique

It is preferable to wait for 20 to 30 minutes after completing the infiltration before initiating liposuction. This brief hiatus allows more complete vasoconstriction and anesthesia, as well as time for the tumescent fluid to move by bulk flow both laterally and deeply and for detumescence of the infiltrated tissue. Detumescence permits the anesthetized tissues to be grasped more easily and accurately without trauma to subjacent tissues.

By carefully grasping the skin and slightly elevating subcutaneous fat, liposuction is initiated at the deepest levels of the fat just above the platysma muscle. Subsequently the cannulas are directed more superficially. Liposuction of the neck can be done more superficially than in other areas of the body, but care is taken not to rasp the undersurface of the dermis with holes of the cannula. The surgeon should not intentionally allow the cannula to rasp the dermis.

Liposuction is accomplished first with the small 20-, 18-, and 16-gauge cannulas, then with the 14-gauge cannula. The larger 12-gauge cannula is rarely used. Smaller cannulas with smaller openings are more likely to give smooth results and are less likely to injure nerves or blood vessels (Figure 35-7).

The marginal mandibular branch of the facial nerve is vulnerable to trauma from a liposuction cannula. Located at the anterior border of the masseter muscle, where it passes over the mandible, the nerve is in close association with the facial artery, the pulsations of which are easily palpated. By elevating the subcutaneous fat away from the subjacent structures, the tumescent technique minimizes the risk of injury to the marginal mandibular nerve.

The surgeon should avoid an aggressive approach to microcannular tumescent liposuction of the cheeks and the portion of the jowls that extends onto the cheeks. Extra caution should be taken in treating the nasolabial folds. It is easy to remove too much fat inadvertently, with a resulting focal depression of the skin.

Postliposuction healing is rapid and uneventful, although subcutaneous fibrosis can occur. The incidence is probably less than 5%. Clinically the patient notices one or more firm, bandlike areas of tightening in the submental area. Histologically these bands show scarring with fibrosis. The condition will resolve spontaneously, and treatment is usually not necessary. For the patient anxious to resolve the fibrosis, the physician can inject very dilute triamcinolone (1 mg/ml or less) into the affected bands and repeat the treatment every 1 to 3 weeks.

Liposuction of the submental area, cheeks, and jowls can be accompanied by skin excision and plication of the submental platysmal muscles to ameliorate a “turkey gobbler” appearance.2

Other applications of microcannular tumescent technique in the head and neck region include facelift and skin cancer repairs using flaps and grafts. Microcannulas without suction are particularly useful in undermining the tightly adherent skin behind the ears and the preauricular skin flaps during facelifts. A standard facelift can be accomplished totally by local anesthesia, without intravenous (IV) sedation, using a microcannular tumescent technique.

Platysma Muscle Plication

Plication of the platysma muscle after tumescent liposuction of the submental area is a simple dermatologic procedure that can be accomplished totally by local anesthesia. Platysma plication tightens the tissue plane defined by the platysma muscles. The cervicomental angle is elevated and becomes more acute and youthful in appearance (Figure 35-8).

If a patient has minimal subcutaneous fat, liposuction alone will likely provide little improvement. Tumescent liposuction, however, although removing little fat, does undermine a skin flap and permits platysma plication with excellent local anesthesia and profound vasoconstriction (Figure 35-9). On the other hand, liposuction of the cheeks, jowls, and area under the chin can provide excellent cosmetic results without platysma plication.

Platysma plication is done after tumescent liposuction. The initial step is to make a symmetric 2.5-cm to 3-cm skin incision in the submental crease. Removing a narrow, 3- to 5-mm-wide transverse fusiform skin excision along the submental crease may yield optimal cosmetic results. An excessive skin excision, however, may limit the range of chin extension.

Thermal Trauma. Using electrocautery for hemostasis, the surgeon must avoid unnecessary thermal trauma to the subcutaneous tissue, which causes prolonged inflammatory swelling and persistent induration. With minimal thermal damage, healing is rapid, and the patient has a normal appearance within a few days without bruising or swelling. I prefer to use a monopolar Hyfrecator unit with a 10-cm (4-inch)–long insulated tip. Bipolar blended cutting/coagulation can be used if care is taken to avoid excessive thermal trauma, which causes prolonged swelling and induration (Figure 35-10).

Retractors (e.g., Army-Navy) are helpful when elevating the dermal flap. It is not necessary to remove every drop of fat from the platysma. Any large residual nodules of fat overlying the platysma can be removed with scissors, being careful not to cause bleeding.

Fibrous Bands. Within the subcutaneous wound the surgeon will encounter numerous fibrous bands attached between the dermis and the connective tissue overlying the platysma muscle. Such fibrous attachments are more numerous distally along the undersurface of the nuchal crease.

Excellent lighting is necessary to see the fine details of the subcutaneous wound. I prefer a fiberoptic head lamp; others might prefer a fiberoptic light mounted on a retractor.

Some fibrous bands contain small but potentially troublesome blood vessels, which should be cauterized before being lysed. Some small vessels and fibers lyse with minimal cautery, whereas larger ones require cautery and cutting with scissors. To avoid inadvertent thermal damage and scarring, the surgeon must always be aware of the proximity of the dermis to the cautery tip.

Suture Placement. Plication of the platysma muscle involves placing inverted or buried interrupted sutures along the midline of the submental and anterior neck. The overall pattern of suture placement is fusiform: the more distal and proximal sutures approximate progressively less tissue, whereas the sutures midway along the neck approximate more tissue (Figure 35-11). Placing the needle through the platysma at the most distal extent requires care and patience. The use of bayonet forceps and needle holders may be helpful.

Tying the suture at the distal extent of the wound can be challenging. With the patient slightly flexing the neck and an assistant elevating the skin with a retractor, the surgeon can pull the suture toward the opening of the incision and thus tie it more easily.

With all plication sutures placed and wound depth reexamined for complete hemostasis, the incision can be closed. By using absorbable, inverted or buried subcuticular 5-0 sutures for strength, cuticular closure is with 6-0 mild-chromic gut (Davis and Geck). If petrolatum or an antibiotic ointment is maintained continuously on the mild-chromic suture, most of the suture will dissolve spontaneously within 5 to 7 days.

Subplatysmal Fat Pad

Although a subplatysmal fat pad exists, targeting this deep fat for tumescent liposuction is rarely, if ever, necessary for good aesthetic results. Blind liposuction that targets the subplatysmal fat is risky and not recommended as a routine procedure.

If the subplatysmal fat pad must be removed, it can be excised under direct visualization by opening the submental compartment. The submental fat pad is in the midline, between the two insertions of the platysma muscles on the mandible. The submental fat pad can be opened by blunt dissection, and if clinically indicated, this small pad can be carefully excised with scissors and electrocautery for hemostasis.

Excision of Redundant Skin

Some patients have redundant skin extending from the submentum to the cricoid cartilage or manubrium. Cosmetic improvement in the profile of such a patient often requires a direct excision of excess skin on the anterior neck (Figure 35-12).

Excision of superfluous skin on the submental and anterior neck area has several variations. One simple procedure is accomplished totally by local anesthesia and involves the following:

  1. Tumescent liposuction
  2. Two perpendicular fusiform excisions
  3. Platysma muscle plication
  4. Wound closure

Tumescent anesthesia, as described earlier, is followed by microcannular liposuction. The first excision removes a narrow, transverse fusiform piece of skin beneath the chin, with the anterior edge coinciding with the submental crease. The second excision removes a larger, longitudinal fusiform piece of skin. After everting and retracting the margins of the longitudinal wound, the platysma muscle is plicated.

Wound closure is accomplished as follows (Figure 35-13):

  1. The edges of the transverse excision are approximated with subcuticular sutures.
  2. The longitudinal fusiform excision is converted into a Z-plasty.
  3. The tips of the Z-plasty are interdigitated and sutured in place with 5-0 nylon using half-buried corner stitches.
  4. Additional interrupted nylon sutures are placed where needed.
  5. A superficial cuticular closure is done along the entire length of the transverse excision and Z-plasty.

Postoperative Care

Application of absorptive compression pads manages the open drainage after CCJ liposuction. In turn, open drainage is necessary to minimize postoperative bruising and edema. A compressive elastic garment is required only for the first 18 to 36 hours after surgery while drainage persists. Once the drainage has ceased, compression may be discontinued.

An elastic compression bandage applied over the cheeks and chin delivers the greatest compressive force over margins of the mandibular rami. To divert some of this compressive force to the submental area, a folded 10-cm (4-inch) gauze pad is placed over the medial submental area. Then a single pad is placed over the folded gauze pad on the submentum; this pad should cover most of the treated area to absorb the limited amount of drainage that follows CCJ tumescent liposuction (Figure 35-14).

Tumescent Facelift

Tumescent facelift (cervicofacial rhytidectomy) performed totally by local anesthesia using the tumescent technique was first reported in 19913 (Figure 35-15). Three years later a tumescent technique for facelift under general anesthesia was reported in the plastic surgery literature.4

Sedation

Tumescent facelift patients do not require systemic anesthesia. The only sedation consists of oral lorazepam (1 mg) the night before surgery. On the day of surgery the patient is usually given oral lorazepam (1 mg) and clonidine (0.1 mg).

Tumescent Anesthesia

After marking the areas of focal accumulations of subcutaneous fat with a felt-tip pen, small blebs are injected at sites of 2-mm to 3-mm incisions, through which the anesthetic needle and the 16-gauge microcannulas will be passed. The tumescent facelift requires 350 to 550 ml of local anesthetic solution containing 500 mg lidocaine, 1 mg epinephrine, and 5 mEq sodium bicarbonate in 250 ml of normal saline. It usually requires 30 to 45 minutes to complete the infiltration without sedation (Figure 35-16).

The infiltration can be performed by an anesthesiologist, a well-trained registered nurse, or the surgeon using a hand-held syringe. The infiltration can be initiated using 12-ml syringes, with a 5-cm 25-gauge needle. In some patients, after the initial infiltration, the surgeon can use more efficient 25-gauge and 20-gauge spinal needles with a foot-controlled peristaltic pump.

Undermining and Liposuction

Areas with little need for liposuction, such as the periauricular skin and superior cheeks, are undermined bluntly using microcannulas without suction. Undermining is done by attaching the microcannula to a microcannula handle, which in turn is attached to the aspirator with power on; the thumb is removed from the air vent. With a nonoccluded air vent, the aspirator provides sufficient suction to remove the small amount of messy tumescent anesthetic solution that would otherwise drip from the cannulas and incisions. Excessive fat on neck and CCJ areas is suctioned with the air vent occluded by the thumb.

After the liposuction and undermining have been accomplished, the patient may go to the bathroom to urinate. On returning, the surgical area is scrubbed and the patient draped in a sterile manner.

Skin Excision

The periauricular incisions are cut and the skin flaps elevated with blunt finger and scissors dissection along the plane previously created by the microcannulas. After careful hemostasis the superficial musculoaponeurotic system (SMAS) plication is completed, the redundant skin trimmed, and the surgical site closed with sutures and staples. Adits (1.5-mm and 2.0-mm skin biopsy punch excisions) permit postoperative drainage.

Step-by Step Sequence

  1. Right side is infiltrated, then the left side.
  2. Right side is undermined or suctioned, then the left side.
  3. Patient visits bathroom.
  4. Periauricular skin on right side is incised, skin flap elevated, residual fibrous connections lysed, and meticulous hemostatis obtained. SMAS plication is performed. Identical sequence is completed on left side.
  5. Hemostasis on right side is checked, skin flap advanced superiorly and posteriorly, redundant skin excised, and wounds closed. Identical sequence is completed on left side.

Ethical Considerations

Dermal Trauma

Two antithetical theories evaluate the benefits of dermal trauma in liposuction. No published objective data support either theory.

According to one theory, liposuction of the chin yields improved cosmetic results if the undersurface of the skin is intentionally injured by mechanical liporaspiration from a cannula or by thermal trauma from a CO2 laser.5 This theory is predicated on the unproven assumption that such iatrogenic scarring will minimize skin redundancy, maximize skin retraction, facilitate skin adhesion to deeper tissues, and maximize cosmetic results.

The contrary theory states that intentionally traumatizing the subsurface of the dermis has no aesthetic benefit. Dermal contraction of the CCJ is the result of natural skin elasticity. The natural negative interstitial tissue pressure relative to atmospheric pressure guarantees an intimate approximation of the skin to the deepest plane of suctioned tissue.6

Advocates of the more gentle technique believe that intentionally rasping the deep surface of the dermis during liposuction is unnecessary and detrimental to achieving optimal aesthetic results. Intentional subdermal trauma, scarring, and fibrotic contraction merely prolong postoperative healing. When excellent results with CCJ liposuction are routinely achieved by avoiding dermal damage, intentionally damaging the skin has no advantage.

When the trauma is substantial, intentional dermal damage requires patients to use postoperative elastic compression for many weeks. Injury to the dermal undersurface causes postoperative fibrosis, focal seromas, prolonged swelling, erythema ab liporaspiration, postinflammatory hyperpigmentation, and impaired healing. With tumescent liposuction, using microcannulas and multiple incisions not closed with sutures, elastic compression bandages are worn for only 18 to 36 hours.

Rasping the platysma muscle directly over the mandible is unnecessary for good results. I have never had a patient with postoperative paresis of the marginal mandibular nerve. Adequate tumescent infiltration and careful liposuction technique with microcannulas prevent nerve injury. The goal of tumescent liposuction is to remove fat while causing minimal collateral trauma or inflammation of residual tissue.

A cosmetic surgeon’s intuitive belief that intentional injury to healthy tissue is beneficial requires objective validation using ethically and scientifically acceptable controls. Surgeons who advocate intentional trauma (mechanical or laser-induced thermal trauma) to the submental wound after liposuction have an ethical and scientific obligation to present the results of objective, controlled studies. It is insufficient to state, “It has been my clinical experience that such trauma is beneficial.”

Factitious Results

With practice a person can selectively contract the muscles that elevate the hyoid bone toward the palate. “Before-and-after” photographs of a patient’s profile can be improved if the patient contracts the anterior neck muscles in the postoperative photograph. Contracting these muscles elevates the base of the tongue and the entire submental compartment, decreasing the angle between the silhouette of the submental area and the neck to almost 90 degrees.

This maneuver gives the appearance of a more youthful silhouette without surgery. Having a patient perform this maneuver improves the appearance of before-and-after photographs and exaggerates the benefits of a technique (Figure 35-17).

Similar ethical considerations require that any before-and-after photographs of CCJ liposuction be accompanied by a listing of all ancillary cosmetic procedures. For example, when illustrating the results of a new liposuction technique, failure to reveal a chin implant might give a deceptive or false-positive impression of the results.

References

  1. Ellis H, Feldman S: Anatomy for anaesthetists, ed 6, Oxford, 1993, Blackwell.
  2. Boskovic DM: Submental lipectomy with skin excision, Plast Reconstr Surg 95:1129, 1993 (letter).
  3. Klein JA: Anesthesia for dermatologic cosmetic surgery. In Coleman WP III, Hanke CW, Alt TH, Asken S, editors: Cosmetic surgery of the skin: principles and techniques, Philadelphia, 1991, Decker.
  4. Brody GS: The tumescent technique for face lift, Plast Reconstr Surg 94:407, 1994 (letter).
  5. Goodstein WA: Superficial liposculpture of the face and neck, Plast Reconstr Surg 98:988-996, 1996.
  6. Guyton AC, Hall JE: Textbook of medical physiology, ed 9, Philadelphia, 1996, Saunders.

Figure 35-1 These two women had tumescent liposuction and platysma muscle plication totally by local anesthesia without intravenous or intramuscular sedation. As these before (A and C) and after (B and D) photographs demonstrate, liposuction can greatly improve the jowls and better define the mandibular margin. Platysma plication can give the submental profile a more youthful appearance. These two women had tumescent liposuction and platysma muscle plication totally by local anesthesia without intravenous or intramuscular sedation. As these before (E and G) and after (F and H) photographs demonstrate, liposuction can greatly improve the jowls and better define the mandibular margin. Platysma plication can give the submental profile a more youthful appearance.

Figure 35-2 CO2 laser resurfacing of entire face can be accomplished by tumescent infiltration. Infiltration technique requires care and gentleness to be tolerated without supplemental systemic anesthesia. The more facial subcutaneous fat that is present, the less discomfort the patient feels during subcutaneous infiltration. A thin patient is more likely to require supplemental injection of midazolam (see Chapter 26).

Figure 35-3 Two-stage “facelift” involving (1) tumescent liposuction with platysma muscle plication and (2) full-face CO2 laser resurfacing using tumescent local anesthesia 4 or more weeks later. A, Preoperative contour drawing. B, Submandibular neck after liposuction and platysma muscle plication. C, Afer liposuction with plication but before full-face CO2 laser resurfacing. D, After liposuction and CO2 laser resurfacing. E, Profile before surgery. F, Profile after liposuction and CO2 laser resurfacing.

Figure 35-4 Tumescent liposuction, platysma muscle plication, and full-face CO2 laser resurfacing. A, Preoperative contour drawing. B and C, Preoperative views. D and E, After tumescent liposuction with platysma muscle plication and 3 weeks after full-face CO2 laser resurfacing.

Figure 35-5 Preferred intraoperative position for liposuction of the chin, cheeks, and jowls (CCJ).

Figure 35-6 A, Location of microincision sites in submandibular chin immediately after tumescent liposuction. Platysma muscle plication is not always necessary. B, Contour drawing accentuates focal fatty deposits. Minimal platysmal bands were present. C and D, Preoperative views. E and F, One day after tumescent liposuction without platysma plication.

Figure 35-7 Delicate tumescent liposuction of medial cheek can be accomplished using 20-gauge Capistrano microcannula and Fine-Touch Aspiration Tubing (see Figure 28-3).

Figure 35-8 Male patient after tumescent liposuction with platysma muscle plication. A and B, Preoperative and postoperative profiles. C, Preoperative contour drawing. D, Submandibular chin/neck area more than 4 months after surgery.

Figure 35-9 Tumescent liposuction with platysma muscle plication is often more acceptable to male patients than traditional facelift. Procedure provides significant improvement without distortion or telltale scars associated with facelift. A and B, Preoperative and postoperative profiles. C, Preoperative contour drawing. D, Submandibular chin/neck area 1 day after surgery. Note incision along submental crease and skin impressions from gauze, absorptive pad, and elastic compression binder.

Figure 35-10 Occasionally, patients develop temporary but disquieting postoperative induration or lumpiness at various locations in submental area. These examples probably have several different causes. Excessive or unnecessary thermal trauma from electrocautery, laser, or ultrasound can significantly impair wound healing. Insufficient postoperative drainage and compression can result in persistent hematomas or seromas. Linear fibrosis and contraction within subcutaneous tissue result in histologic appearance of scar tissue. Redundant skin or insufficient liposuction can produce a liponot in any location, including tissue distal to submental crease. Thermal trauma should be avoided. In these patients, resolution of fibrosis was facilitated by (1) intralesional injections of triamcinolone (2 mg/ml) at intervals of 1 to 3 weeks and (2) excision of a narrow fusiform strip of skin and open removal of focal residual fat.

Figure 35-11 Platysma muscle plication technique. A, Subcutaneous platysma muscles with relative location of inverted or buried plication sutures along anterior neck. B, Suture path through overlying fascial tissue and platysma muscles of anterior neck. C, Platysma after suture is tied. D, Plicated platysma muscles after sutures are tied.

Figure 35-12 Skin resection with Z-plasty, immediately after tumescent liposuction and platysma muscle plications, can effectively eliminate excessive submandibular skin. A and B, Preoperative views. C and D, Postoperative results. E, Immediate postoperative view of submandibular neck with sutures in place. F, Submandibular excision and Z-plasty 6 weeks after surgery.

Figure 35-13 Submental skin excision and Z-plasty. A, Two perpendicular fusiform excisions of skin from submental neck. B, Edges of transverse excision are approximated with subcuticular sutures. Z-plasty incisions are made along longitudinal fusiform excision. C, Z-plasty is completed with half-buried corner stitches and 6-0 mild-chromic sutures.

Figure 35-14 Postoperative dressings after liposuction of CCJ. A, Small superabsorbent pad is positioned over treated area to manage open tumescent drainage. B, Elastic compression binder provides adjustable and comfortable compression to treated area.

Figure 35-15 Facelift performed totally by local anesthesia using tumescent technique in 1989. A, Preoperative view. B, Appearance 48 hours after tumescent facelift with minimal ecchymosis and minimal edema.

Figure 35-16 Sequential plasma lidocaine concentrations measured in eight women after tumescent facelift totally by local anesthesia (1989 to 1991). Typical lidocaine dosage was 15 mg/kg. Peak plasma lidocaine concentrations ranged from 0.3 to 1.1 μg/ml.

Figure 35-17 Factitious cosmetic improvement from A to B represents effects of muscle contraction. No liposuction or other cosmetic surgical procedure was done. This maneuver must be considered when evaluating “before-and-after” photographs.

Scientific Publication

  1. Klein, JA. Optimal Statistical Techniques in Estimating Patient Compliance. Preventive Med, 1979.
  2. Klein JA, Cole G, Barr RJ, Bartlow G, Fulwider C. Paraffinoma of the Scalp, Arch Derm 121:382-385,1985.
  3. Klein JA, Barr RJ. Verrucous Hemangioma, J Pediat Derm, 2:191-193,1985.
  4. McCullough JL, Peckham P, Klein J, Weinstein GD, Jenkins JJ. Regulation of epidermal proliferation in mouse epidermis by combination of difluoromethyl ornithine (DFMO) and Methylglyoxal Bis(guanylhydrazone) (MGBG), J Invest Derm 85:518-521,1985.
  5. Klein JA, McCullough JL, Weinstein GD. Topical tritiated thymidine for epidermal growth fraction determination. J Invest Derm 86:406-409,1986.
  6. Klein JA, Barr RA. Diffuse lipomatosis and tuberous sclerosis. Arch Derm 122:1298-1302,1986.
  7. Klein JA. The tumescent technique for liposuction surgery. J Am Acad Cosmetic Surg 4:263-267,1987.
  8. Klein JA. Anesthesia for liposuction in dermatologic surgery. J Derm Surg Oncol 14:1124-1132,1988.
  9. Stewart JH, Cole GW, Klein JA. Neutralized lidocaine with epinephrine for local anesthesia. J Dermatol Surg Oncol 15:1081-1083,1989.
  10. Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Derm Surg Oncol 16:248-263,1990.
  11. Klein JA, Barr RJ. Bannayan-Zonana Syndrome Associated with Lymphangiomyomatous lesions. J Pediat Dermatol 7:48-53, 1990.
  12. Klein JA. The Tumescent Technique: Anesthesia and Modified Liposuction Technique. Dermatol Clinics 8:425-437,1990.
  13. Stewart JH, Chen SE, Cole GW, Klein JA. Neutralized lidocaine with epinephrine for local anesthesia, II. J Dermatol Surg Oncol 16:842-845,1990.
  14. Klein JA, Anesthesia for dermatologic cosmetic surgery. Coleman WP III, Hanke CW, Alt TH, Asken S, editors, Cosmetic Surgery of the Skin: Principles and Techniques. Philadelphia, B. C. Decker Inc. 1991, pp 39-45.
  15. Coleman WP III, Klein JA. Use of the tumescent technique for scalp surgery, dermabrasion, and soft tissue reconstruction. J Dermatol Surg Oncol 18:130,1992.
  16. Klein JA, Soins post-operatoires apres liposculpture utilisant la technique tumescente (Postoperative Care Following Liposuction by the Tumescent Technique), La Revue de Chirurgie Esthetique de Langue Francaise 17:5-8,1992.
  17. Klein JA. Tumescent technique for local anesthesia improves safety in large volume liposuction. Plast Reconstr Surg 92:1085-1098,1993.
  18. Klein JA. Reply: Ethics of promoting patient safety and comity among surgical specialties. [letter] Plast Reconstr Surg 95:603-604,1995.
  19. Klein JA. Establishing a Dermatologic Surgicenter, Elson M, editor, Evaluation and Treatment of the Aging Face. Springer-Verlag, publishers, New York 1995, pp 255-260.
  20. Klein JA, Liposuction. Moy R, Lask G, editors, Principles and Techniques of Cutaneous Surgery. Mc Graw-Hill, New York, 1996, pp 529-542.
  21. Klein JA, Tumescent liposuction and improved postoperative care using Tumescent Liposuction GarmentsT. Dermatol Clinics, 13:329-338, April 1995.
  22. Klein JA, Tumescent Technique Chronicles: Local Anesthesia, Liposuction, and Beyond. Dermatologic Surg. 21:449-457, 1995.
  23. Klein JA, Epitomes, Dermatology: Tumescent technique for local anesthesia. West J Med 124) Klein JA. Tumescent liposuction with local anesthesia. Principles and Techniques of Cutaneous Surgery. Lask GP, Moy RL editors. McGraw-Hill, New York, 1996. pp 529-542.
  24. Klein JA, Anesthesia for dermatologic cosmetic surgery. Coleman WP III, Hanke CW, Alt TH, Asken S, editors, Cosmetic Surgery of the Skin: Principles and Techniques. 2nd Edition. Philadelphia, B. C. Decker Inc., 1997
  25. Klein JA. Two Standards of Care for Tumescent Liposuction. Derm Surg J 24:1194-1195,1997
  26. Klein JA, Kassardjian N. Lidocaine Toxicity with Tumescent Liposuction, a case report of probable drug interactions. Derm Surg J 24:1169-1174,1997
  27. Klein JA, Tumescent Liposuction, Chapter 9, in Dzubow LM, editor, Cosmetic Dermatologic Surgery, Lippincott-Raven, Philadelphia, 1998,p163-169.
  28. Klein AW, Narins RS, Klein JA. Tumescent Liposuction. Fitzpatrick's Dermatology in General Medicine, 5th edition, McGraw Hill, New York, 1999, pp2967-2969.
  29. Klein, JA. Intravenous fluids and bupivacaine are contraindicated in tumescent liposuction (letter), Plastic Reconstr Surg 102:2516-2518,1998.
  30. Klein JA. Anesthetic formulations of tumescent solutions. Dermatologic Clinics, 17:751-759,1999.
  31. Klein JA. Post-tumescent liposuction care: open drainage and bimodal compression. Dermatologic Clinics, 17:881-889,1999.
  32. Klein JA. Commentary: Fulton J. Modified Tumescent Liposuction. Dermatol Surg 25:764-766,1999.
  33. Klein JA. Discussion: Perry AW, Petti C, Rankin M. Lidocaine is not necessary in liposuction. Plast Reconstr Surg. 1999 Nov;104: discussion 1903-6
  34. Klein JA. Antibacterial effects of tumescent lidocaine. Plast Reconstr Surg. 1999 Nov;104:1934-6.
  35. Klein JA, Tumescent Technique: Tumescent Anesthesia & Microcannular Liposuction. Mosby, St. Louis, approx 500 pages. March, 2000.
  36. Klein JA. Pharmacology of Tumescent Liposuction. Ch 21. pp 443-445. In Cosmetic Surgery: An Interdisciplinary Approach, Narins RS editor, Marcel Dekker, New York, 2001.
  37. Klein JA Liposuction Using Dilute Local Anesthesia: Counterpoint. Dermatol Surg 29:1146-7, 2003.
  38. Klein JA, Is Tumescent Liposuction Safe?, Baran R, Maibach HI, Editors, Textbook of Cosmetic Surgery, 3rd ed. 2005, Chapter 64, pages 621-628, Taylor&Francis Publishers, London&New York (ISBN 1-84184-311-3)
  39. Kucera IJ, Lambert TJ, Klein JA, Watkins RG, Hoover JM, Kaye AD. Liposuction: contemporary issues for the anesthesiologist. J Clin Anesth. 18:379-87, 2006.