TITLE: CERVICOFACIAL LIPOSURGERY
SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds
DATE: December 6, 1995
RESIDENT PHYSICIAN: Christopher Thompson M.D.
FACULTY: Karen Calhoun M.D. FACS
SERIES EDITOR: Francis B. Quinn, Jr., M.D.
to Grand Rounds Index|
"This material was prepared by resident physicians in partial fulfillment of
educational requirements established for the Postgraduate Training Program of
the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended
for clinical use in its present form. It was prepared for the purpose of stimulating
group discussion in a conference setting. No warranties, either express or implied,
are made with respect to its accuracy, completeness, or timeliness. The material
does not necessarily reflect the current or past opinions of members of the UTMB
faculty and should not be used for purposes of diagnosis or treatment without
consulting appropriate literature sources and informed professional opinion."
Liposuction involves the removal of unwanted adipose tissue, usually via a
Lipoinjection attempts to augment subcutaneous deficiencies with fat cells
placed through a needle and syringe.
Liposuction and transplantation were both described by 1850, and by 1911
histopathology of transplanted adipose was described. Peer quantified the
volume reduction in post-transplanted fat in 1950, reporting that 55%
remained after one year. Liposuction using a cannula was begun in the early
1900ís using a uterine curette, but the technique abruptly fell out of favor
when a well-known ballerina required the amputation of her leg after a
vascular injury Experimentation with sharp curettes continued through the
1960ís and 70ís until the modern method, using blunt suctioning was
introduced by Fournier and Illouz in 1978. Lipoinjection applications in the
head and neck began with Brunings in 1911 as he attempted to correct nasal
deformities secondary to rhinoplasty. Facial recontouring using the
injection of fat was developed by Bircoll who introduced the technique in
Anatomy and Physiology
The architecture of subcutaneous fat is pictured in figure 1, and consists of
adipocytes organized into lobules by a surrounding network of septae and
capillaries. The thickness of the fat determines its blood supply. Fat
greater than 1cm thick receives a greater share of its blood through
ascending fascial arteries. Fat less than 1cm depends on descending branches
of the subdermal plexus. This anatomy explains the findings of skin dimpling
due to fat atrophy after liposuction in thin areas when the cannula is
directed upward and the subdermal plexus is disturbed. Application of this
knowledge also helps to provide more dramatic results in areas of thick fat
by directing the cannula over the fascia to disrupt the important part of the
blood supply. Cervicofacial fat tends to be more stable in both its volume
and distrubution than fat stores elsewhere, so that generalized weight loss
may actually accentuate these areas. Genetic factors seem to be very
prominent in the makeup of subcutaneous cervicofacial fat. Surgical removal
of fat in this area has provided good long-term results in those patients who
exercise and control dietary intake
Retractability of the skin after liposuction strongly influences the outcome
of all the body sites the neck, is by far the area of greatest
retractability. The meeting point between the facial and cervical areas, the
jowls, exhibit similar adaptability. Studies regarding cell viability after
liposuction harvest reveal that the lobular architecture remains undisturbed
through cannulas larger than 16 gauge, and that a greater vacuum pressure
enhances viability. Histologic examination of transplanted fat reveals
cystic cavities surrounded by relatively normal fat architecture Larger
volumes of injected fat created larger cavities with associated fibrosis.
Six to nine months are required for graft stabilization, and 20 - 25% of the
graft volume should remain
Indications For Liposurgery
The most common application involves the restoration of the chin-neck contour
in order to create a cervicomental angle of approximately 100 degrees.
Liposuction of the face has indications when combined with rhytidectomy,
particularly in patients with excessive preparotid, nasolabial, and malar fat
pads. Loose skin in the jowls can be lastingly improved after suction
lipectomy alone, but results are enhanced with concomitant facelift
procedures. Many surgeons now use liposuction in the submental, cheek,
lateral neck, and nasolabial fold before developing routine rhytidectomy
flaps, making them easier to dissect. Liposuction techniques have recently
been described in the excision of lipomas of the head and neck. Recontouring
of both free microvascular and locoregional flaps in the head and neck is
another recent application of liposuction. ˇ
Preoperative Planning For Liposuction
Preoperative counseling is important to ensure realistic expectations - the
patient must understand that changes may continue 6 - 8 months
post-operatively. In the sitting position the lower border of the mandible
is marked, as is the extension of the jowls below. Palpation of the fatty
areas allows the creation of a topographical map on the face and neck. The
medial border of the platysma is then marked if possible.
Technique - Liposuction
Anesthesia is accomplished with a combination of local infiltration and
intravenous sedation. A great variety of cannulae are available, but for
facial liposuction the 2 to 6 mm blunt-tipped versions are universally
accepted. Cannula size has a significant effect on the post- operative
contour of the skin; there is a reduction in surface irregularities by using
more passes with the smaller cannula. The cobra-tipped cannula has greater
usefulness in areas of dense, fibrotic tissues, but is more likely to cause
neural, vascular, and skin damage. Both metal and plastic cannulae are
available The vacuum pumps only requirement is that it generates at least 1
atmosphere of negative pressure.
The Oweto technique of liposuction has become widespread in liposuction of
other body areas. This involves the infiltration of a hypotonic saline
solution containing lidocaine and epinephrine which not only decreases
bleeding, but assists in the development of tissue planes and the
dislodgement of fat in the head and neck. This method loses attractiveness
as it distorts the surgical field making determination of contour and volume
Closed techniques describe the use of liposuction without adjunctive
procedures such as rhytidectomy. The ideal incision is small and slightly
distant from the localized area of excess fat, and is placed in an
inconspicuous site such as the submental area or just inferior to the ear
lobe. The entrance for the cannula is created with blunt tipped scissors,
which is then oriented along the plane of dissection by rolling the fat with
the other hand, the tissues are stabilized as the cannula is used. Dry,
pre-tunneling with gradually enlarging cannulae is felt by some to help
dissection and prepare the wound for the passage of the larger cannulae;
others advocate beginning with the desired size with suction. Once the
appropriate size is reached, the dissection is performed with suction in a
radial fashion as each tunnel is created with 10 to 12 passages of the
cannula. Lateral dissection with the cannula is not advised as good evidence
exists to support the idea that the septae between the tunnels contain
Although pictured differently, most surgeons agree it is imperative that the
suction port be directed downward at all times to avoid dermal damage and
post-operative atrophy leading to dimpling in the neck, the plane of
dissection is between the dermis and the platysma. For more dramatic
results, some surgeons advocate the removal of subplatysmal fat in the
submental region, between the medial borders of the muscles. Great care must
be taken in this instance to avoid the appearance of an unnaturally thin
neck. This technique is similar among the other sites of the head and neck;
these figures illustrate approaches to the lateral neck, jowls, cheek, and
melolabial regions. Applications in the face must be undertaken with care to
avoid dissecting above the Frankfort horizontal, and within 2 cm of the oral
commissures; facial nerve injury is common after dissection in these areas.
Determination of the correct amount of fat to remove is obviously subjective,
but preoperative planning as well as intraoperative palpation give
indications as to the appropriate stopping point. Postoperative care
consists of a support bandage, usually neoprene, which is worn continuously
for the first week followed by 3 weeks at night; in almost all cases, this
compressive dressing obviates the need for drains.
Open liposuction is performed beneath a skin flap under direct vision and is
nothing more than a combination of liposuction and rhytidectomy. Various
methods of combining the two procedures exist . Teimourian uses the cannulae
to develop the skin flaps, followed by sharp dissection with the scissors to
take down the intervening septae. This, he claims, dramatically reduces the
time for flap elevation. Others use the suction cannula to remove fat
overlying the SMAS (superficial musculoaponeurotic system) once the flaps are
elevated, and perform the submental liposuction through the existing
Recently, liposuction assisted debulking of pedicled and free flaps have been
described. Complications for these procedures are essentially those of
rhytidectomy. They include hematoma, platysmal banding, recurrence, skin
dimpling and irregular contourinq, and facial nerve paresis/paralysis.
Much of our knowledge concerning the histology of transplanted fat comes from
Peers work in the 1950s. This work is responsible for cell survival theory
which explains that a certain percentage (40-60%) of the transplanted
adipocytes survive. Older theories describe the process of histiocytic
replacement of the fat cells with subsequent fibrosis. The survival of the
graft is dependent on the reanastomosis with the host vasculature rather than
neovascularization, although the nonsurviving cells are not necessarily
located in the grafts center.
More modern studies examining transplantation of suctioned fat confirm Peers
work and provide guidelines for harvesting and injection. The use of vacuum
suctioning harvest produces viable grafts when the negative pressure is
maintained at 0.5 atmospheres or lower. Some surgeons, however, advocate
manual suction techniques. Both harvest and injection should be done through
an 18 gauge needle or larger to maintain graft viability.
Applications of lipoinjection
For the aging face, six sites for augmentation have been described including
the nasolabial folds, oral commissures, mentum, glabellar frown line,
inframalar groove, and cheek hollows. Some of the other indications include
depressed scars, depressed skin grafts, hemifacial atrophy, facial
lipodystrophies, and parotidectomy defects. Other applications exist, but
this technique is useful only for subcutaneous ugmentation, and will not
benefit areas in which there are dermal irregularities.
Attention to sterile technique throughout the procedure is vital, as
infection rates have been quoted to be between 2 and 3%; more recently, toxic
shock syndrome was reported following lipoinjection of the face. Choices for
donor sites are numerous. Areas of low vascularity such as the trochanteric
region, or the upper part of the inner thigh seem to be the most attractive.
In thin individuals it is sometimes necessary to use the more vascular,
periumbilical area. Augmentation of small (<2ml) defects is performed most
easily with a syringe and an 18 gauge needle. Incremental deposition of the
fat seems to produce better longevity in the graft. Some authors suggest
0.1 ml volumes while others use up to 1.0 ml. Overcorrection of 20 - 30 %
seems to be the most effective. Larger defects (2 - 20 ml) will require a
small liposuction cannula and a small incision. Limited undermining of the
defect may be necessary to achieve an even distribution. As in the smaller
defects, incremental deposition provides better results. Resorption seems to
be more prominent with larger volumes of transplantation with most authors
suggesting overcorrection of 50%. Fat handling - a variety of treatments
have been devised to prepare the harvested adipocytes for transplantation.
The simplest and most widely used is a saline wash to remove dead tissue,
debris, and blood which theoretically increases the bacteriologic medium
Others suggest that wrapping the harvested fat in cottonoids acts to
concentrate the graft prior to injection. More involved techniques include
insulin baths designed to decrease lipolysis and increase the glycogen and
lipid formation within the cells. Eppley used bovine basic fibroblastic
growth factor and was able to demonstrate a greater proportion of intact fat
cells compared with controls.
Many surgeons remain skeptical about the long term results of
lipotransplantion as a result of several early studies demonstrating poor
results due to atrophy. More recent histological and clinical studies now
suggest that with meticulous technique for harvest, transfer, and deposition
excellent long term results can be achieved. In addition to handling of the
grafts, overcorrection of the defect is imperative for satisfying
post-operative aesthetics. 20-30% is best for overcorrection for defects 2ml
or less, while 30-50% overcorrection is better for larger defects.
Bailey BJ. Head and Neck Surgery - Otolaryngology. Philadelphia: JB
Lippincott, 1993. p2309
Boyce RG. The use of autogenous fat, fascia, and nonvascularized muscle
grafts in the head and neck. Otolaryng. Clinics of North Am. 1994;27(1):39.
Goddio AS. Suction lipectomy; the gold triangle of the neck. Aest. Plast.
Kamer FM. Submental Surgery. Arch Otolaryngol Head Neck Surg. 1991;117:40.
Moreno A. Esthetic contour analysis of the submental cervical region. J
Oral Maxxilofac. Surg. 1994;52:704.
Niechajev I. Long-term results of fat transplantation: clinical and
histologic studies. Plastic and Reconstructive Surgery 1994;94(3):496.
Perkins SW. Use of submentoplasty to enhance cervical recontouring in
face-lift surgery. Arch Otolaryngol Head Neck Surg 1993;119:179.
Rhee CA. Toxic shock syndrome associated with suction assisted lipectomy.
Aesth. Plast. Surg. 1994;18:161.
Teimourian B. Suction Lipectomy and Body Sculpturing. St Louis: C V Mosby
Company, St Louis 1987 p65.
Wooden AW. Liposuction-assisted revision and recontouring of free
microvascular tissue transfers. Aesthetic Plastic Surgery 1993;17:103.