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NECK LIPOSUCTION OF FACE-LIFT? Ó PJWMDPA For many women between 30 and 50 (maybe even 60's) years of age, an important decision related to changing the shape of their necks is whether or not to have neck liposuction or a face lift. First, let us discuss face lifting. Face lifting is a surgical procedure in which skin is usually cut out of the cheeks, beginning with the skin just surrounding the ears. The remaining cheek and neck skin is loosened then pulled tight toward and around the ears. That skin is basted back upon the ears as a "hiding zone" in an effort to camouflage the resulting scars. Even the best face-lift results in a visible scar. The question is whether or not the visible scar is a fine one. The main difficulty men and women (especially younger ones) undergoing face-lifting encounter is that once the skin and tissues are stretched, cut out, and thrown away, the remaining tissue and skin will be stretched and made irreversibly thinner. The body does not let the facial dermis (leather layer), which is the principle layer causing smoothness, or the thin overlying epidermis grow any thicker after a face-lift. There is no chance that this tissue will return to its pre–face-lift thickness. Saving and re-injecting the cut out face tissue in a laboratory (tissue banking) doesn't thicken the overall skin either. With all face lifts come the risk that important nerves (nerves important both to muscles and feeling) may be cut and that and that other damage may occur. Even in the hands of the best doctors, nerve problems have occurred, . Fortunately, these problems are not too common, and the face-lift is a good weapon in the fight against aging when it is used properly. Younger patients are reminded that it may be a good idea to delay a face-lift (especially in very young patients, those who are <35 years of age) until improved technology comes along or until a later date necessitates it. Patience might just save these patients future and unnecessary cosmetic procedures. For example, the first face-lift typically "lasts" seven years, because "virgin" skin is stretched. In order to "maintain" the first result, a second face-lift might have to be done at that time on the stretched skin. Then, a third lift may need to be done four years later, depending upon how "tight" the patient wants the face. By the time a patient is 60 years old and following multiple face-lifts, his/her friends can see every blood vessel just like a road map through his/her thin-skinned face. Are there alternatives to face-lifting? Yes, but it depends upon each individual patient and, of course, upon the capabilities of the surgeon who the patient chooses. One particular surgeon may be so good with one technique that he/she is able to get great results in patients in whom most other doctors could not possibly have achieved similar results (using the same technique). The best surgeon would be one who is so skilled in all the available techniques that the good results overlap the boundaries of the procedures that could be done. In this way, patients could make the choice of treatments based upon the amount of surgery necessary and upon the risks, benefits, cost, and expected length of time that good results will last. Some of the alternatives to face lifting include facial liposuction, limited neck-lifting, subdermal laser application, external (resurfacing) laser treatments, and chemical peeling. Of course, importance and usefulness of alternatives depends upon what particular problem the patient wants treated. Fine lines respond best to laser. Cheeks do tighten with facial liposuction, but a turkey-gobbler neck will rarely, if ever, go away. There are many different types of face-lift that attack many different problems; a future chapter is in the works to address the many types of face lifting. Let us now proceed to discuss face and neck liposuction. Not everyone is a candidate for neck liposuction. There are several structures that make up the bulk of the neck. These hidden and important internal structures help determine the way the neck looks from the outside. These structures include the laryngeal cartilage (Adam's apple, which is larger in men), the hyoid bone, the tongue muscle, and the platysma muscle (sheet-like muscle) and the fat which lies between the platysma and the surface dermis (leather layer) of the skin. Salivary glands can enlarge and become part of the picture as well. Since only fat can be removed by liposuction and only platysma muscle can contract after being liposuctioned, the outcome of a liposuction will be greatly affected depending upon which of the structures is more or less prominent. The platysma is a sheet-like muscle that extends from the lower jawbone all the way to the collarbone of the neck. It is thin and spread like a sheet. The platysma is usually fairly tight in younger people. However, the noticeable thin bands in older women, which also give the turkey-gobbler look, are usually the result of the platysma. Platysma bands eventually become thick and cord-like, which causes them to tent the skin of the neck as they contract, tether or dangle between the jawbone and the collarbone. The combination of platysma and fat is the primary concern if a patient is just to have a neck liposuction without any surgery to improve the platysma. Take, for example, a 40-year-old woman with a lot of fat in the neck, which is covering or hiding what would normally be (if they were thin) bands or cords of platysma. If the fat is sucked away via liposuction alone, unsightly bands of platysma may be left behind especially if they do not respond by self-tightening or dermal tightening related to the liposuction. It is best to have a surgeon who is capable of tightening the platysma or of anticipating platysma problems (if these arise along with the liposuction); several special stitch techniques usually improve platysma bands with good success. Occasionally, it may be very difficult to detect some platysmal bands, since they are soft, floppy muscles and can be easily hidden in fat. It is much easier to detect a protruding hyoid bone or an outstanding laryngeal cartilage, or Adam's apple. It is easy to feel the solid, relatively firm muscle of the tongue and sometimes the submandibular glands or salivary glands under the angle of jaw. None of these hard structures, including muscle or bone, can be removed by liposuction; liposuction simply removes fat. If a patient has large tongue muscle or a big hyoid bone, sucking overlying fat away may simply allow those structures to be more easily seen by the public. It is important to consider that before you have neck liposuction that your surgeon should touch and feel the underlying structures of the neck. If the structures of the neck are found to be uniform and are lying deep within a soft fatty layer, then removing that fatty layer should leave none of these structures standing out, none that are prominent or unsightly. Remember that digital photography and imagery can be very unrealistic, especially when we are dealing with body areas that are made of several layers Liposuction of the neck can have one benefit; in fact, it is desirable for the liposuction of the neck to cause a hidden, sheet-like scarring in the neck. The sheet-like scarring in the neck is brought about by the diffuse trauma (controlled and spread-out damage) caused by the liposuction cannula in the fatty layer. Remember that wherever the liposuction cannula passes, it may suck out and remove some fat, but in its wake it leaves a tunnel, which eventually scars and therefore possibly contracts. The tunnel will collapse back and respond to injury by forming fiber cells, which make up scar tissue. This very desirable net-like arrangement of scar tissue caused by the interconnecting tunnels of the liposuction cannulae will contract and give one a tighter neck. Many times the contraction following neck liposuction is strong enough to prevent the platysma bands from being seen, because the contraction forms a sling of tight neck skin and dermal tissue. Unfortunately, this does not always happen; and generally the younger the patient, the better result of neck liposuction. Still, remembering the structures we just talked about; no matter what your age, if those structures are not proper for the neck liposuction, the final result may leave something to be desired. The neck is one of the most popular sites for liposuction. Neck liposuction alone takes the Web site author about 30 minutes to perform; the author places the Klein tumescent numbing solution in about 20 minutes and then suction takes about ten minutes. In neck liposuction, as is the custom, tiny skin entrance wounds are made with a scalpel just under the chin and just in front of the ears. Usually the surgeon will pass (use) a spatula-type cannula that is relatively flat at the tip. A spatula is usually the most desirable type of cannula to use in the neck. A bullet-shaped cannula would tend not to track as easily along the proper plane or path in the neck. In the neck, unlike most of the rest of the body it is best to keep the cannula very close to the underside of the dermal (leather layer) of the skin. The cannula opening may point into the fat layer below or may scrape the dermis above in order to cause tightening. The face and neck are the only parts of the body in which this cannula superficial scraping process may be accomplished with some safety (see chapter on Superficial Liposuction). A spokewheel pattern is created of liposuction cannula paths or tracks, and the vacuum is then turned on and the paths revisited to suck out whatever fat will come. Do not expect much fat to be removed during a neck liposuction. Remember that the most desirable results of the neck liposuction probably come from damaging the undersurface of the skin; this controlled damage causes overlying tissue contraction. Similar effects (those that come from damaging the undersurface of the skin) have been seen following the "modified weekend face-lift" by Dr. Cook of California. Unfortunately, the laser that Dr. Cook uses and the manner in which he passes the laser are not able to be precisely controlled. There is no feedback for use in controlling the laser energy other than looking with the naked eye and stepping on a foot pedal. There have been occasional reports of disfigurement and undesirable tissue bonding and scarring in patients treated with this technique, but Dr. Cook assures me that a modification in the technique (not lasing the very center of the neck tissue) has greatly reduced these problems. Most patients can tolerate the extra uncontrolled damage to the undersurface of the skin. But in some patients with common medical conditions there may not be as much room for trouble, such as diabetics, smokers, or those with blood vessel diseases. In the future, there will likely be more accurate ways to deliver laser to the undersurface of the skin in order to gain the desired contraction without causing external skin death or scarring in any patients. For now, the traditional spatula liposuction cannula may be one of the best friends a surgeon can have in causing the tightening of the tissues of the neck. What are the pros and cons of neck liposuction? On the pro side, the procedure is fairly simple, and many surgeons can obtain fairly good results with very little training. Probably the most important thing these new doctors to the field can be trained in is patient selection. A properly selected patient is probably more important to the outcome than is the way in which the procedure is done, with the exception that damaging the mandibular nerve (a RARE event) can cause a permanent smile palsy. The marginal mandibular nerve runs in different paths around the angle of the jaw. Sometimes even experienced surgeons get too close to this nerve, thereby causing damage. Patients then cannot smile properly for up to six months, or, perhaps, even permanently. Unfortunately, overly aggressive liposuction in these areas can cut or permanently damage the nerve, leaving patients with complete paralysis and an irregular smile for the rest of their lives. It is important to choose a neck liposuction surgeon who has had quite a bit of experience. A surgeon with little training might be able to do nine and ten liposuctions of the face fairly well, but it could be that one bad result could be catastrophic. In many patients, liposuction of the face can usually be done without intravenous sedation. However, if you are slightly squeamish or cannot tolerate the infiltration of the Klein solution, it may be best to have a board-certified anesthesiologist present. The presence of a nurse anesthetist may be sufficient as described in previous chapters. The procedure usually takes the author about one-half hour, from the administration of the Klein solution to the application of the garment for the liposuction of the neck. In summary, other cons of neck liposuction include the risks associated with potential of irregular liposuction ("ruffles" under the neck), of damaging the nerves (resulting in an irregular smile), and of oversuctioning of the neck (resulting in a divot). Another positive comment about neck liposuction is that it can be paired with a procedure called platysmal plication (tying together). In the case of platysmal plication, the entrance wounds used to make a liposuction canal underneath and between the ears leave a path or canal that can be used to see and tie together the separate platysma muscle bands, using stitches or supports. Tight bands will no longer flop or flap, especially after fat is removed from the area via liposuction. Additionally, face liposuction alone does not leave the large amount of internal scarring damage that face-lifts leave. Face liposuction alone leaves much less scarring around the ears. Often, 45–55year-old female patients can obtain a good result or tightening of the face or neck with liposuction alone. This may be much more practical than entering into a chronic (long) cycle of continuing face lifts requiring the skin to be stretched and cut out around the ears. Remember that once you do a face-lift, there is always cutting and stretching of tissue, the remaining tissue or skin never gets any thicker ever! Many times the author has found the combination of neck and cheek liposuction useful in younger female patients. It helps contract the tissues below the leather layer of the skin and may be used in combination with a full-face laser of the surface skin to remove sun-damaged skin and wrinkles. Depending upon the patient, the Web site author may choose to separate these two procedures with a skin "rest period"— face/neck liposuction and laser face resurfacing.
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