Cervicofacial liposuction as a primary procedure is not for all patients. The successful use of this procedure is dependent on the surgeon's ability to select patients whose anatomic attributes and psychological profile indicate that they are appropriate candidates for liposuction. A succinct diagnosis of the prevailing pathology is paramount. Liposuction is not for the patient with unrealistic expectations or for the patient with excess skin and little fat.
When contemplating cervicofacial liposuction, the surgeon must consider the skin tone, as well as the muscular support of the neck, the skeletal configuration, and the patient's overall body habitus. Kamer and Lefkoff13 have developed a submental evaluation algorithm that assesses anatomic properties and equates these findings with the most appropriate surgical option. Conley15 showed that the position of the hyoid bone in relation to the mentum is the most significant determinant of a desirable cervicomental angle. A low, anterior hyoid position will produce a less favorable result in liposuction than a high, posteriorly placed hyoid (Fig. 19-1).
Figure 19-1 Liposuction of the neck and submentum produces the most well-defined cervicomental angle if the hyoid bone is positioned high and posterior. (A) However, a low and anterior hyoid limits the desired appearance of the neck in liposuction and should be noted preoperatively and discussed with the patient as a limitation. (B) (From Conley J. Facelift operation. Springfield, IL: Charles C Thomas, 1968:40-41. With permission.)
Addressing the submentum with this system is a good starting place, but palpation and the physician's judgment are key factors. Ideal candidates for liposuction as a primary procedure have good skin elasticity and overall muscle tone and are of average weight for their height. Those who demonstrate localized adipose deposits that are out of proportion to the remainder of the body will benefit most from a localized fat removal procedure. Skin elasticity and muscle tone usually are good indicators of postoperative skin contraction and redraping of the soft tissue envelope; therefore, younger patients are generally more appropriate candidates. Overweight patients should be at the lower end of their usual range, with any planned weight loss taking place 6 months prior to the procedure. In general, women have greater elasticity to the skin and are better candidates for closed cervicofacial liposuction as a primary procedure (Fig. 19-2).
Women tend to have thinner, less sebaceous skin that contracts over the reduced subcutaneous bed. This is not to say that men are not to be considered for this procedure but rather that expectations for this subset must be tempered. Women also tend to show more dramatic and earlier changes.10,16 Patient selection is less of an issue when liposuction is used as a secondary procedure, when its addition enhances a favorable outcome from another procedure, especially a chin implant or facelift.
Inappropriate candidates for cervicofacial liposuction are those who present with prominent wrinkling of the skin, significant ptosis to the muscular sling, and prominent platysmal bands. Redundant and inelastic skin often fails to redrape appropriately after the removal of moderate to large amounts of subcutaneous fatty deposits.5,16-20 Exceptions certainly do occur and these patients may have remarkable results (Fig. 19-3).
Figure 19-3 (A) Preoperative. Older patient with cervicofacial fat as well as redundant skin who refused rhytidectomy. (B) Two months postoperatively, after liposuction and nasal surgery only. Excess skinfolds persist, but with dramatic cosmetic result. (From Kridel R, Konior R, Buchwach K. Suction lipectomy. In: Krause CJ, Mangat DS, Pastorek N (eds). Aesthetic facial surgery. Philadelphia: JB Lippincott, 1991. With permission.)
Whereas too much extra skin may impede appropriate skin redraping, some extra skin is necessary to allow for recontouring of the newly created cervicomental angle. The problem of platysmal banding will not be eliminated with cervical liposuction and may be exacerbated by fat resection. The patient with significant submental fat may have postliposuction exposure of previously masked platysmal banding. The patient with significant banding or cording should be informed preoperatively of the need for either a playtsmal plication or a full rhytidectomy for optimal results.
Finally, skin irregularities and asymmetries, hyoid position, and chin projection should be noted and discussed with the patient. Such irregularities such as dimpling, depressions, and scarring will not improve with liposuction alone and may be more pronounced. Hyoid bone position and chin projection will dictate the acuity of the cervicomental angle, and patients should be aware of the limitations imposed by anatomic structures. Ideally, a high and posteriorly positioned hyoid and a strong chin will allow for better creation of the acute submental angle deemed youthful.
