Kỹ Thuật Bậc Thầy Trong Trẻ Hóa Khuôn Mặt

15. Ramirez OM, Robertson KM: Update in endoscopic forehead
rejuvenation. Facial Plast Surg 2002;10(1):37-51.
16. Ramirez OM: Three-dimensional endoscopic midface
enhancement: A personal quest for the ideal cheek
rejuvenation. Plast Reconstr Surg 2002;109(1):329-340.
17. Ramirez OM: Cervicoplasty: Non-excisional anterior approach.
Plast Reconstr Surg 1997;99(6):1576-1585.
18. Giampapa VC, DiBernardo BE: Neck recontouring with suture
suspension and liposuction: An alternative for the early
rhytidectomy candidate. Aesthet Plast Surg 1995;19(3):
217-223.
19. Guerro-Santos J: The neck lift. In Vistnes LM (ed): Procedures
in Plastic and Reconstructive Surgery: How They Do It.
Boston: Little, Brown, 1991, p 153.
20. Ramirez OM: Mandibular matrix implant system: A method to
restore skeletal support to the lower face. Plast Reconstr Surg
2000;106(1):176-189.
21. Bartlett SP, Grossman R, Whitaker LA: Age-related changes in
the craniofacial skeleton: An anthropometric and histologic
analysis. Plast Reconstr Surg 1992;90(4):592-600.
22. Gonzales-Ulloa M: Ptosis of the chin: The witch’s chin. Plast
Reconstr Surg 1972;50:54.
23. Coleman SR: Facial recontouring with lipostructure. Clin Plast
Surg 1997;24(2):347-367.
24. Feinendegen DL, Baumgartner RW, Schroth G, et al: Middle
cerebral artery occlusion and ocular fat embolism after
autologous injection in the face. J Neurol 1998;245(1):53-54.
25. Moon SY, Chang GY: Images in clinical medicine. A
complication of cosmetic surgery. N Engl J Med
2004;350(15):1549.
26. Ramirez OM: Cervicoplasty: A nonexcisional anterior
approach. A 10-year follow-up. Plast Reconstr Surg
2003;111(3):1342-1345.
27. Feldman JJ: Corset platysmaplasty. Plast Reconstr Surg
1990;85(3):333-343.
28. Ramirez OM, Heller L: Facial rejuvenation. In Peled IJ,
Manders EK (eds): Esthetic Surgery of the Face. London:
Taylor & Francis, 2004, pp 73-90.
29. Sozer O, Biggs TM: Our experience with endoscopic brow lifts.
Aesth Plast Surg 2000;24(2):90-96.
30. De Cordier BC, de la Torre JI, Al-Hakeem MS, et al:
Endoscopic forehead lift: Review of technique, cases, and
complications. Plast Reconstr Surg 2002;110(6):1558-1568.
31. Knize DM: Reassessment of the coronal incision and subgaleal
dissection for foreheadplasty. Plast Reconstr Surg
1998;102(2):478-489.
32. Chiu ES, Baker DC: Endoscopic brow lift: A retrospective
review of 628 consecutive cases over 5 years. Plast Reconstr
Surg 2003;112(2):628-633.
196
Oscar M. Ramirez • Charles R. Volpe

HISTORY
Tessier was one of the earliest surgeons to utilize
autogenous bone grafts in the 1960s to correct congenital
and traumatic deformities of the facial skeleton.1 Donor
site morbidity, prolonged operative time, and resorption
of tissue grafts limited the widespread use of these
techniques. Alloplastic implants were first introduced in
the late 1960s when Spadafora and Hinderer pioneered
the use of synthetic implants for aesthetic facial
enhancement.2,3 Since that time, many other prominent
surgeons have advocated the use of alloplastic implants
for facial aesthetic surgery.4-9
The use of facial implants continued to grow beyond
its indication for malar augmentation. As early as the
1970s, Gonzalez-Ulloa recognized the ability of midface
implants to rejuvenate the midface when performed with
standard rhytidectomy.4 Most of his work focused on
improving facial appearance by altering cheek shape and
contour. This “profileplasty” was a natural progression
from the earlier craniofacial techniques popularized by
Tessier and others. Many realized that midface augmen-
tation could produce fuller cheeks and a more youthful
appearance. However, the emphasis of this early work was
more on improving the overall shape of the face, rather
than reversing the effects of aging on the midface.
After extensive modification of early implant proto-
types, Binder advocated the use of midface augmentation
as an independent and powerful method for midface
rejuvenation in the 1980s.10 An important innovation in
Binder’s work was the increased emphasis on submalar
“soft tissue” augmentation, which he showed could have
a significant impact on midface aesthetics by restoring the
volume lost because of atrophy associated with the aging
process. In the 1990s, Terino further promoted alloplastic
facial contouring as a way of improving the overall facial
aesthetics.11
PERSONAL PHILOSOPHY
The last two decades have seen rapid advances in the
understanding and treatment of midface aging.10,12-16
Midface rejuvenation has evolved far beyond the
rhytidectomy procedure to involve deeper and more
fundamental levels of dissection with attempts at
elevating and replacing lost midface volume. The
pathophysiology of the aging process is a key factor in
determining the correct surgical treatment. It is now well
understood that the aging process results not only in the
descent of the midface but also in the atrophy of the soft
tissue in multiple facial planes. Midface rejuvenation can
therefore be achieved not only through suspension
techniques but also by the augmentation of the soft tissue
and skeletal foundation. As a result, we have found that
alloplastic implants are an effective way to alter the
midface appearance in appropriate candidates. Midface
augmentation is a straightforward, long-lasting, and
relatively low-risk surgical option that can consistently
and predictably improve midface aesthetics. It has the
ability to replace lost facial soft tissue volume and to
increase the anterolateral projection of the area, thereby
reducing midface laxity and decreasing the depth of the
nasolabial folds (Fig. 12-1). Implants are readily reversible
and can be combined with standard rhytidectomy proce-
dures. The net effect is a softening of the sharp angles and
depressions of the aged face, resulting in a natural
“unoperated” look. In appropriate candidates, moderate
facial rejuvenation can be achieved simply with the
placement of submalar midface implants without con-
comitant rhytidectomy (Fig. 12-2). This technique is
particularly applicable to middle-aged patients (ages 35
to 45 years) who show early signs of facial aging and
atrophy without significant soft tissue laxity of jowls or
deep neck rhytids.
In patients who require rhytidectomy because of
significant lower facial laxity, alloplastic implants can also
augment the bony scaffold of the malar region, thereby
improving the fundamental base upon which facial tissues
are suspended. This midface recontouring allows for
dramatic results that are not possible with soft tissue
techniques alone. The benefit is especially apparent in
patients who have a combined deficiency of the facial
skeleton and soft tissues, and in those patients who have
a prominent malar skeleton but lack adequate submalar
soft tissue. Midface implant augmentation facilitates
rhytidectomy in several ways. The skin and soft tissue can
be draped over a broader, more convex midface region
Aesthetic Midface Implants
William J. Binder, MD, FACS • Brian P. Kim, MD • Babak Azizzadeh, MD, FACS
197
C H A P T E R T W E L V E

after implant augmentation (Fig. 12-3). There is also
minimal traction on the perioral tissues and lateral
commissure if placed prior to the rhytidectomy, which can
help to avoid an “overoperated” appearance. Similarly,
the subperiosteal dissection of the midface during the
implant placement also releases the deep attachments of
the superficial musculoaponeurotic system (SMAS) to the
facial skeleton, allowing greater mobilization and
suspension of ptotic soft tissues, which greatly enhances
the results of sub-SMAS and deep plane rhytidectomy.12
198
William J. Binder • Brian P. Kim • Babak Azizzadeh
A
B
A
B
Figure 12-1 Suspension effect of
midface implants. Midface implants
augment the facial skeleton and
restore soft tissue volume. The
combined effect is to relocate the soft
tissue to a more anterosuperior
location and restore the hollow
regions of the midface.
Figure 12-2 Facial rejuvenation with submalar
implant. Preoperative (A) and 3-year postoperative
(B) views of a 45-year-old woman with type II
submalar atrophy who underwent three-submalar
implant placement.

Many patients who present for revision rhytidectomy and
require volume restoration can also be improved by
expanding the midface region while decreasing downward
vertical traction forces on the lower eyelid.
The deep plane facelift, subperiosteal facelift, and fat
grafting have become popular methods for improving the
aesthetics of the midface.12-18 These techniques can be
useful alternatives to alloplastic implants in appropriate
candidates; however, they do have limitations in
addressing the underlying pathophysiology of midface
aging. The subperiosteal midface lift and deep plane
rhytidectomy can have a tremendous impact on the midface
by suspending the existing soft tissue but cannot replace
the deeper or superficial soft tissue that is lost with aging.
Furthermore, subperiosteal midface lifts cause significant
edema and distortion to the periorbital region that can
last for several months. Facelift surgery may even worsen
the overall appearance by “skeletonizing” the face in
patients with significant midfacial volume loss or extremely
prominent bone structure.
Injectable soft tissue fillers such as hyaluronic acids,
calcium hydroxylapatite, and collagen can efface the
nasolabial fold, but they seldom yield permanent results
or produce significant volume enhancement. They may
serve as a valuable option in treating early stage
nasolabial fold and facial atrophy in younger individuals.
Injectable poly-L-lactic acid (Sculptra, Dermik Aesthetics,
Bridgewater, NJ) may be able to produce more dramatic
volume enhancement than other fillers but generally
requires yearly maintenance. Free fat transfer can also
produce moderate volume augmentation, but long-term
results and longevity are not predictable.
Midface implants not only help reverse the effects of
aging, but they are also useful in a variety of other
conditions. Midface contouring can mask post-traumatic
and congenital deficiencies while avoiding lengthy
reconstructive surgeries and graft donor site morbidity.19
Implants can improve the facial atrophy that results from
anorexia nervosa or the effects of protease inhibitors in
treating conditions such as human immunodeficiency
virus (HIV) lipodystrophy (Fig. 12-4).20 We have also
successfully used facial implants for patients with
longstanding facial paralysis and Bell’s palsy who have
significant unilateral facial and muscle atrophy.
ANATOMY
Youth is marked by an abundance of facial soft tissue,
allowing for full cheeks and smooth, pleasant contours
without sharp irregularities or indentations.21 The aging
process begins to appear in persons who are in their 30s
and 40s and significantly progresses by the time
individuals reach their 50s and 60s. The effects of the
midface aging process are a result of volume loss, the
gradual descent of soft tissue, and decreased skin elasticity.
CHAPTER 12
Aesthetic Midface Implants
199
A
B
Figure 12-3 Convexity effect of midface implants. Facelifts generally stretch skin over a flat midface structure in a two-dimensional pattern (arrows in A).
Malar and submalar implants create a more convex midface region allowing for a more natural skin draping and resulting in a third dimension for facial
rejuvenation (arrows in B).

The malar, buccal, temporal, and infraorbital fat pads
atrophy and lose their fascial support, becoming progres-
sively ptotic secondary to gravity. The malar fat pad,
suborbicularis oculi fat (SOOF), and orbicularis oculi
muscle descend inferiorly, causing an exaggeration of the
nasolabial folds and exposure of the infraorbital rim.
Cavitary depressions and submalar hollowness may
develop in addition to the deepening nasolabial and
nasojugal folds. The end result is flattening of the midface
with an aged and fatigued appearance, often unmasking
underlying bony anatomy.
Surgical treatment of the aging face requires a keen
understanding of the soft tissue and bony landmarks of
the midface. The malar eminence is a key element that is
localized to the anterior one third of the zygomatic arch,
and is a common area of implant augmentation.
200
William J. Binder • Brian P. Kim • Babak Azizzadeh
A
B
C
Figure 12-4 Submalar midface implants for treatment of HIV lipodystrophy. Preoperative (A, C, and E) and 1-year postoperative (B, D, and F) views of
a 34-year-old man who underwent customized submalar implant placement.
D
E
F

Placement of implants in individuals who have a normally
developed malar region can lateralize the apex of the
cheek and result in a high and angular malar eminence.
The submalar triangle is bound superiorly by the
zygomatic prominence, medially by the nasolabial fold,
and laterally by the masseter muscle. It is another vital
region of the midface that can be contoured, resulting in
the correction of midface volume loss (Fig. 12-5). The
submalar triangle is the most common site of midface
deficiency in the aging face and can be easily rejuvenated
with alloplastic implants.
CHAPTER 12
Aesthetic Midface Implants
201
PREOPERATIVE ANALYSIS
All patients who present for facial rejuvenation undergo a
complete history and physical examination. Photographs
and digital imaging aid in determining the exact nature of
the patient’s concerns. Photographs taken from the basal
and apical bird’s eye view can help determine the degree
of midface volume loss and asymmetry and aid in the
selection of appropriate implants. When evaluating a
patient for midface rejuvenation, it is important to
determine the relative contributions of soft tissue
inadequacy and skeletal deficiency. Skeletal and soft
tissue asymmetry is also an important consideration in the
preoperative consultation. Asymmetries may become
exaggerated postoperatively if not diagnosed and
accounted for by modifying the implants at the time of
surgery. In addition to assessing the midface, it is also
important to analyze and address the upper and lower
face. Many patients who are candidates for midface
augmentation will also require other surgical procedures
to enhance the overall facial aesthetics. Midface implants
can be performed in conjunction with standard
rhytidectomy and blepharoplasty with excellent outcome.
To assist in determining the appropriate facial
implant, it is best to recognize the characteristic patterns
of midface deformity (Table 12-1).22,23 It is very
important to separately evaluate the bony malar region
and the soft tissue component in the submalar area.
Patients with type I deformity have primary malar
hypoplasia with ample midface soft tissue. This deformity
is best addressed with malar shell implants that cover the
bony midface, resulting in a high arched, laterally
projected cheek (Fig. 12-6). The newer shell implants are
more stable and less prone to migration when compared
to traditional malar “button” implants.
Type II submalar deficiency occurs in patients who
have normal malar skeleton associated with soft tissue
Table 12-1
Patterns of Midface Deformity
Types
Description of Deformity
Augmentation Required
Implant
Type I
Primary malar deficiency
Lateral malar projection and
Malar shell implant with slight
and hypoplasia
augmentation
extension into the submalar space
Inadequate malar bony prominence
to create a soft transition
Adequate submalar soft-tissue
Type II
Primary submalar deficiency
Restore midface volume with
Submalar implant placed over the
Normal malar projection
anterior projection of the
anterior maxilla and messeteric
Flattened and deficient submalar
submalar space
tendon with slight extension onto
soft-tissue
the malar eminence to create a soft
transition
Type III
Combined malar and submalar deficiency
Restore complete midfacial
Combined malar and submalar
Malar hypoplasia
volume by both anterior and
implant
Submalar volume deficiency
lateral projection of submalar
and malar regions
Figure 12-5 Submalar triangle. The submalar triangle is bordered
superiorly by the zygomatic prominence, laterally by the masseter muscle,
and medially by the nasolabial fold. It is the most common area of deficiency
with aging.

atrophy of the midface. This is the most common
deficiency found in the aging face as the soft tissue
components of the midface start to atrophy and lose
luster. Soft tissue atrophy and inferior descent leave a
hollowed-out appearance, resulting in a flat and dull-
appearing midface. Type II deficiency is best treated with
submalar implants that fill in the midface depressions and
give greater anterior projection to the flattened face (Figs.
12-2, 12-7, and 12-8).
Type III deformity occurs when there is a combined
bony malar hypoplasia and soft tissue deficiency. These
patients have the propensity to suffer exaggerated effects
of aging because ptotic soft tissues have little bony
support and readily descend along the nasolabial folds
and oral commissure. Type III patients can greatly benefit
from the placement of combined malar-submalar
implants (Fig. 12-9). Many of these patients would be
poor candidates for rhytidectomy alone, because there is
202
William J. Binder • Brian P. Kim • Babak Azizzadeh
A
B
C
D
Figure 12-6 Type I midface deformity.
Preoperative (A and C) and postoperative
(B and D) photographs of a patient with
type I malar hypoplasia who has relative
deficiency of the midface skeleton and
underwent placement of malar shell
implants.

limited underlying skeletal support with which to
resuspend the skin and soft tissue. The surgical results are
often suboptimal and short-lasting.
SURGICAL TECHNIQUE
GENERAL GUIDELINES
Biomaterials such as silicone, polytetrafluoroethylene
(Medpor, Porex Surgical Products, Newnan, GA), and
expanded polytetrafluoroethylene (Gore-Tex, W.L. Gore
& Associates, Inc., Flagstaff, AZ) can be used for midface
augmentation. We prefer silicone because it is flexible, has
a low incidence of infection, and can be easily inserted
and removed.6-11 The transoral approach is utilized to
place the implant in a subperiosteal pocket. This
approach allows easy insertion of the implant and direct
visualization of all midface anatomic structures
(especially the infraorbital nerve). There are no external
skin scars and the inferior dissection helps avoid
postoperative traction on the lower eyelid. In the
CHAPTER 12
Aesthetic Midface Implants
203
A
B
C
D
Figure 12-7 Type II midface deformity.
Preoperative photographs (A and C) of a patient
with type II submalar deficiency. The patient had
adequate facial skeleton but deficiency of the
submalar soft tissues. Seven-year postoperative
photographs (B and D) after placement of submalar
and chin implants demonstrating the long-term
enhancement of facial rejuvenation.

subperiosteal plane, silicone implants become firmly
attached to the facial skeleton by capsular fibrosis, which
helps ensure against implant migration during the
postoperative period.23 A potential disadvantage of this
approach is the increased risk of wound infection; the
implant could be contaminated by oral microbes because
it is placed through the mouth. Fastidious surgical
technique can help to reduce this risk. Occasionally, other
approaches such as the subciliary and lateral facelift
approaches are utilized.
When performing concomitant rhytidectomy, the
surgeon can insert the implants before or after the facelift
surgery. Type I and III patients, who have a malar
component to the midface augmentation procedure,
should have the implants placed prior to the rhytidectomy
so that the surgeon can compensate for the structural
changes that may not be obvious after swelling occurs.
When implants are placed prior to the facelift procedure,
it is prudent to place a Penrose drain into the oral
incisions to prevent seroma and hematoma formation.
204
William J. Binder • Brian P. Kim • Babak Azizzadeh
A
B
C
D
Figure 12-8 Type II midface deformity
with dermatochalasia and lower facial laxity.
Preoperative (A and C) and postoperative (B and
D) photographs of a patient with type II submalar
deficiency, aging eyes, and lower facial laxity who
underwent placement of submalar implants,
facelift, and upper and lower blepharoplasty.

Type II patients who will require only submalar soft tissue
augmentation can undergo the rhytidectomy procedure
prior to the implantation. The advantages of placing the
alloplastic implant at the end of the procedure include
maintaining a dry implant pocket, reducing subperiosteal
bleeding, and closing the intraoral wound immediately
following the augmentation, thereby reducing the risk of
infection.
PREPARATION FOR SURGERY
Patients are started on a broad-spectrum oral antibiotic
the day before the procedure. In the preoperative holding
area, crucial areas of the midface are marked on the face
while the patient is sitting upright (Fig. 12-10). The
markings include the midface volume deficit, areas of
depression, infraorbital nerve axis, and the malar
CHAPTER 12
Aesthetic Midface Implants
205
A
B
C
D
E
F
Figure 12-9 Type III midface deformity. Preoperative (A, C, and E) and postoperative (B, D, and E) photographs of a patient with type III volume-deficient
face who lacks adequate facial skeletal structure and soft tissue bulk who underwent placement of combined malar-submalar implants with enhanced
midface volume and overall improvement of facial aesthetics.

eminence. The infraorbital nerve lies along the
midpupillary line when the patient is staring straight
ahead, and denotes the medialmost border of the typical
midface implant. The patient is asked to smile broadly to
help determine the most inferomedial position of the
implant and to ensure that there is no interference with
facial mimetic function. After the skin marking, the
patient can look into a mirror and decide if the proposed
changes will satisfy his or her expectations.
Implant placement can be performed using
intravenous sedation or general anesthesia. Intravenous
antibiotic and steroids are routinely utilized. After an
adequate anesthetic state is reached, 1% lidocaine with
epinephrine is injected into the gingival-buccal sulcus and
the midface in a subperiosteal plane. Hyaluronidase
(Wydase, Wyeth-Ayerst, Philadelphia, PA) is added to the
anesthetic solution to help disperse the local anesthetic
evenly and minimize contour irregularities from the
accumulation of fluid. The face is then massaged in order
to disperse the solution evenly. The operative site is prepared
with povidone-iodine (Betadine, Purdue Frederick,
Norwalk, CT) from soaked gauze sponges placed into the
gingival-buccal sulcus at the level of the canine fossa for
10 minutes.
INCISION AND DISSECTION OF MALAR
EMINENCE
A 5-mm stab incision is made in the gingival-buccal
sulcus over the lateral canine fossa and maxillary buttress
(Fig. 12-11). It is unnecessary to make a large incision,
because the mucosa can stretch to accommodate larger
implants. The incision is made in an upward oblique
direction and is carried immediately and directly onto the
maxillary bone. Compression of the mucosa against bone
during incision will help minimize bleeding. At least a
1-cm cuff of gingival mucosa is left to facilitate closure at
the end of the procedure. Dentures can remain in place
during the operation, as they will not interfere with
implant insertion and actually direct the placement of the
incision to the correct location.
The periosteum of the anterior maxilla is elevated
superiorly and laterally (Figs. 12-12 and 12-13). The
surgeon’s external free hand is crucial in guiding the
direction and extent of dissection using the preoperative
markings. The subperiosteal elevation is started with
the Joseph elevator but is quickly changed to a broader
10-mm Tessier elevator (Fig. 12-14). Extensive
dissection, stretching, and traction around the infraorbital
foramen are avoided. If the proposed implant is large or
has a significant medial component, the infraorbital nerve
is carefully identified in order to avoid placement of the
implant over the foramen.
Dissection is extended laterally to the malar-zygo-
matic junction and zygomatic arch. The subperiosteal
plane is utilized for dissection particularly over the lateral
zygomatic arch where branches of the facial nerve
traverse just superficial to this plane (Fig. 12-15). Gentle
blunt dissection over the midzygomatic arch will help
avoid injury to the temporal branch of the facial nerve. A
broad instrument is far safer than a delicate thin elevator.
Thin elevators can more easily puncture the periosteum
laterally, where there is limited visibility during the
dissection.
EXPOSURE OF THE SUBMALAR TRIANGLE AND
CREATION OF AN IMPLANT POCKET
The submalar space requires exposure in patients with
types II and III midface deficiencies. The submalar space
206
William J. Binder • Brian P. Kim • Babak Azizzadeh
Figure 12-10 Preoperative markings. With the patient sitting upright,
the areas of midface deficiency requiring augmentation are marked. The
infraorbital nerve axis along the midpupillary line designates the medial
border of dissection.
Figure 12-11 Oral incision. The gingival-buccal incision is made over
the lateral canine fossa. Only 5 mm is required as the initial incision, because
the mucosa will stretch and provide adequate exposure of the midface
skeleton. A 1- to 1.5-cm cuff of gingiva is maintained inferiorly.

CHAPTER 12
Aesthetic Midface Implants
207
Figure 12-12 Periosteal elevation. The periosteum is elevated over the
maxilla superiorly and laterally. The borders of dissection are the masseteric
tendon and infraorbital rim.
A
C
B
Trigeminal n.
A
B
Figure 12-13 Midface dissection. The outlined area in A represents the extent of the malar and submalar dissection. The dashed area in B represents the
submalar dissection over the superior tendinous origin of the masseter muscle.

is an anatomic hollow that extends about 3 cm below the
zygoma. To expose this region, the subperiosteal
dissection is continued inferiorly below the zygoma and
over the superior tendinous origin of the masseter muscle.
The glistening white tendinous attachment of the masseter
can be visualized by gentle elevation of the overlying soft
tissue from the deeper plane of the tendon (Fig. 12-16).
The muscle attachments are not divided because they are
a crucial platform for the lateral portion of the submalar
implant. Posteriorly the submalar space becomes much
narrower and is not easily accessed. The posterior limit is
carefully dissected by advancing a blunt elevator along
the inferior border of the zygomatic arch. Masseter
contraction at its superior border tends to be limited,
thereby preventing postoperative implant displacement.
A pocket is created over the malar-zygomatic
complex and submalar triangle that is large enough to
accommodate the appropriate implant. The implant
should easily fit into this dissected space, which should
always be larger than the implant without any com-
pression by the surrounding tissues, especially in the
posterior region. An implant that is forced into an
inadequately sized pocket will become displaced. If the
posterolateral portion of the pocket is inadequately
exposed, constriction of this area will push the implant
anteriorly and cause migration or extrusion. One should
be able to move the implant at least 3 to 5 mm in all
directions. In general, the periosteum and soft tissues
reapproximate immediately after surgery and obliterate
the dead space within 24 to 48 hours.22
INSERTION OF IMPLANT
The location and size of the implants are typically deter-
mined preoperatively depending on the facial analysis,
type of deformity, and patient desires. When choosing the
appropriate midface implant, it is best to use an implant
that is slightly smaller than the desired volume changes,
in order to account for the bulk of the overlying soft tissue
and fibrous capsule formation. Malar shell implants for
type I deformity rest on top of the malar and zygomatic
bone in a more superior and lateral position (Fig. 12-17).
Submalar implants for type II deformity generally lie over
the anterior face of the maxilla. Combined malar-
submalar implants for type III deformity will cover both
the malar bony eminence and the submalar triangle.
Positioning an implant in the submalar triangle is more
subjective than placement over the malar eminence
requiring a greater judgment to effect the desired facial
contour changes.
208
William J. Binder • Brian P. Kim • Babak Azizzadeh
Figure 12-14 Periosteal elevators. Periosteal elevation begins with the
narrow elevator to gain initial access, but most of the dissection should be
performed with the broad 10-mm Tessier elevator (shown in this figure).
Submalar
space
Figure 12-15 Facial nerve branches in the region of dissection. It is
crucial to dissect in the subperiosteal plane over the zygomatic arch in order
to avoid injury to the temporal branch of the facial nerve. The use of a broad
elevator will help prevent perforation of the periosteum in this region. The
buccal branches are also at risk if the masseteric dissection is not performed
carefully.
Figure 12-16 Submalar triangle and masseteric tendon. The lateral
aspect of the dissection will be over the masseteric tendon, inferior to the
lateral zygomatic arch. In this region, the soft tissues are gently elevated
over the glistening white fibers of the tendon, allowing placement of the tail
of the submalar implant.

Sizers should be used to determine and confirm the
appropriate implant shape and size. The actual implants
should be placed in antibiotic solution (Bacitracin 50,000
U/L) at the beginning of the procedure and allowed to
soak until insertion. A variety of implant sizes and shapes
should be available in the operating room, and the
surgeon must be ready to customize these implants
(Fig. 12-18). Shaving an implant by even 1 mm can have
a significant impact on the final result, especially in
patients with thin facial skin.
It is very important to assess for facial symmetry
following the insertion of the implants. A ruler can be
used to measure the distances from the medial border of
the implants to the midline. Preexisting facial asymmetry
can be very challenging, requiring exquisite attention to
the bony and soft tissue topography (Fig. 12-19). As a
CHAPTER 12
Aesthetic Midface Implants
209
Type I
deformity
Malar
implant
Type II
deformity
Submalar
implant
Type III
deformity
Combined
submalar
shell implant
A
B
Figure 12-17 Implant placement. Malar
shell implants for type I deformity rest on top of
the malar and zygomatic bone in a more
superior and lateral position (A). Submalar
implants for type II deformity generally lie over
the anterior face of the maxilla (B). Combined
malar-submalar implants for type III deformity
will cover both the malar bony eminence and
the submalar triangle (C).
C

result, each implant may need to be asymmetrically
contoured and positioned. Standing at the head of the
table helps in evaluating for contour symmetry after both
implants have been placed. This is particularly evident in
patients who have particularly thin skin or prominent
facial skeleton. In these patients, the edges and contours
of larger, thicker implants tend to be palpable with visible
irregularities if not addressed during the initial procedure.
SECURING THE IMPLANT
After final placement, the implant will need to be secured.
Larger implants that are not prone to migration within a
210
William J. Binder • Brian P. Kim • Babak Azizzadeh
Figure 12-18 Intraoperative carving of implant.
Figure 12-19 Facial asymmetry. This patient has
a very common pattern of facial asymmetry (A and
C). The patient’s right side is narrower with malar
eminence in a higher position and more projected.
The left side is wider, flatter, and more posteriorly
displaced. Postoperative photographs (B and D) after
placement
of
asymmetrical
midface
implant
placement. A medium malar shell implant was placed
in the right side, whereas a large combined malar-
submalar implant was placed in the left side of the
face.
A
B
C
D

relatively tight pocket may not require fixation. Several
methods can be used to fix the implant in order to avoid
postoperative migration. We prefer to use external suture
fixation using one of two techniques.23 The first technique
is an indirect lateral suture fixation. Long (10-inch)
double-armed Keith needles on 0-0 silk suture are passed
through the lateral end of the implant (Fig. 12-20). These
needles are then placed into the wound and are directed
posterolaterally, exiting the temporal region behind the
hairline. The implant is then placed into the final position
and the sutures are tied over a cotton roll bolster. This
method is best for malar shell implants (type I deformity)
by applying a superolateral tension on the implants and
maintaining their position over the bony malar-zygomatic
eminence.
The second suture technique is a direct external
fixation (Fig. 12-21). This method is better for submalar
and combined malar-submalar facial implants (type II
and III deformities). It is also the preferred technique
when the implants have excessive mobility within the
wound pocket. Midface implants usually have two
preformed fenestrations. The position of the medial
fenestration should be marked on the external skin while
the implant is inside the subperiosteal pocket. Locating
these holes can be achieved with a right-angle clamp that
pushes the implant upward, underneath the fenestration,
causing an external protuberance that can be marked on
the external skin. Symmetry is confirmed by measuring
and comparing the distance of each marking to the
midline. After marking the medial fenestrations, the
implants are removed and placed on top of the midface.
The implants are positioned to coincide with the desired
contour and preoperative markings; the second mark is
then made on the skin to coincide with the location of the
lateral fenestration of the implant. Double-armed 3-0 silk
sutures are used to go through the medial and lateral
fenestrations with the loop around the deep surface of the
implant. The needles are then placed into the wound
pocket and passed perpendicularly through the skin
markings corresponding to each fenestration. The implant
is then brought into the pocket, ensuring proper position
and symmetry. The sutures are gently tied over cotton roll
bolsters overlying the anterior cheek. These bolsters help
compress the midface and reduce any potential dead space
and prevent fluid from collecting in the subperiosteal
pockets. External sutures and bolsters are removed 24 to
48 hours after operation.
If implants are placed prior to a concurrent rhytidec-
tomy procedure, they can be secured with internal suture
fixation, which allows the oral incision to be completely
closed. If external suture fixation is desired, the implant
should be left in place with the oral incision temporarily
or loosely closed. When the rhytidectomy is completed,
the oral incision is reopened in order to fix the implant
with external sutures. Intraoral Penrose drains can be
placed if required.
WOUND CLOSURE AND DRESSING
The intraoral incisions are copiously irrigated with
antibiotic solution and closed in one layer with chromic
sutures. Bandages are then placed over the external suture
bolsters and an elastic facial dressing is applied. We prefer
a full elastic garment dressing that applies even midface
compression (CaroMed International, Tucson, AZ) and
remains in place for 24 hours (Fig. 12-22). The suture
bolster closes the midface pocket anterior to the implant
while the elastic dressing applies adequate pressure to
obliterate the pocket posterior to the implant. The
patients are encouraged to use this elastic dressing after
the bolsters are taken out for an additional 24 to
48 hours. If performed with rhytidectomy, a lighter neck
and facial compression dressing composed of cotton and
cling is also used.
POSTOPERATIVE CARE
Postoperatively, the patients can recover at home or an
aftercare facility. They are encouraged to use ice packs for
3 to 4 days and sleep with the head elevated. All patients
are prescribed antibiotics, analgesics, and antinausea
medication. The first follow-up appointment is on post-
operative day 1 or 2 when facial dressings and external
sutures are removed. At this time, any drains placed
CHAPTER 12
Aesthetic Midface Implants
211
Figure 12-20 Indirect lateral suture fixation. This method is best used
for malar shell implants (type I deformity) by applying a superolateral
tension on the implants and maintaining their position over the bony malar-
zygomatic eminence. Long (10-inch) double-armed Keith needles on 0-0
silk sutures are passed through the lateral end of the implant and directed
posterolaterally, exiting the temporal region behind the hairline. The implant
is then placed into the final position and the sutures are tied over a cotton
roll bolster.

212
William J. Binder • Brian P. Kim • Babak Azizzadeh
A
B
C
D
E
F
Figure 12-21 Direct external fixation. Direct external fixation allows precise fixation and is best suited for submalar and combined implants in type II and
III patients. The implant is adjusted in the pocket to obtain the exact desired location (A). A right-angle clamp is utilized to mark the location of the implant
fenestrations by pressing behind the fenestration outward through the facial skin and marking the area of protuberance (B). A second fenestration mark is
placed to ensure adequate orientation. Symmetrical placement of markings is checked (C). The suture needles are passed perpendicularly through the skin
markings corresponding to each fenestration (D–H).

CHAPTER 12
Aesthetic Midface Implants
213
Figure 12-21 Continued. After ensuring precise location and adequate
fixation of the midface implants, the sutures are tied over a cotton roll bolster
(I–J). Benzoin and a flexible bandage can then be placed over the bolster (K).
G
H
I
J
K

during rhytidectomy are also removed. Patients are then
seen on a regular basis until facial edema resolves. The
patients are generally able to return to routine activity
5 to 7 days following the procedure. About 80% to 85%
of the edema will resolve within 3 to 4 weeks. The
remaining 15% to 20% of facial edema will gradually
resolve over the ensuing 6 months.
COMPLICATIONS
The most frequent complications of facial implants
include malposition and choosing an incorrect implant.6,24
Postoperative displacement may result from incorrect
positioning, insufficient pocket size, or inadequate
fixation of the implant. Other complications include
bleeding, hematoma, and seroma. It is important to assess
the patients within 48 to 72 hours after surgery to ensure
against significant facial asymmetry. The placement of
drains can help prevent fluid collection, especially when a
concurrent rhytidectomy is performed or when there has
been excessive bleeding during the procedure.
The rate of infection for alloplastic silicone implants
is about 1%.24 Soaking the implant in antibiotic solution,
irrigating the wound pocket, and preventing the
accumulation of fluid and blood in the surgical pocket can
all help to minimize the risk of infection. Implant
extrusion is extremely rare and usually occurs through the
intraoral incision due to an inadequate dissection of the
posterolateral pocket. Other complications include
infraorbital and facial nerve injury. Infraorbital numbness
can persist from days to weeks postoperatively but is
rarely permanent. Damage to the frontal branch of the
facial nerve can occur during dissection of the zygomatic
arch, and the buccal branch could be injured with
aggressive masseter dissection.
Future Directions
Alloplastic implants will continue to gain a more
prominent role in facial aesthetic surgery. Currently,
computer technology allows for more precise facial
implants that can be customized for correcting complex
facial defects.19,20 Computer-aided design (CAD) and
manufacturing (CAM) of implants starts with a high-
resolution computed tomographic (CT) scan of the face.
A precise life-size three-dimensional model is then
computer-generated via stereolithography. The surgeon
then creates a custom silicone implant template using this
model along with direct analysis of the patient’s face that
can also be facilitated with a moulage. This template is
then used to produce a mold and ultimately a silicone
implant that precisely fits the topography of the bony
skeleton with the desired surface contour. These custom-
designed prostheses are especially useful for cases of
severe facial asymmetry seen in patients with
longstanding facial paralysis as well as congenital and
post-traumatic defects. The late stage sequelae of facial
trauma can be especially difficult to treat with
conventional open reduction and internal fixation. In
this setting, camouflage with custom implants can be an
effective and straightforward way to achieve facial
symmetry and normalcy, while avoiding lengthy,
extensive reconstructive surgery and donor site
morbidity.
REFERENCES
1. Tessier P: The definitive plastic surgical treatment of
the severe facial deformities of craniofacial dysostosis:
Crouzon’s and Apert’s diseases. Plast Reconstr Surg
1971;48(5):419-442.
2. Spadafora A, De los Rios E, Toledo Rios R: Pomulos planos
(platizigion): Endoprotesis de polietileno insertadas por via
sub periostica de arco cigomatico [Flat cheeks: Polyethylene
endoprostheses inserted subperiosteally along the zygomatic
arch]. Prensa Med Argent 1971;58(40):1946-1950.
3. Hinderer UT: Malar implants for improvement of the facial
appearance. Plast Reconstr Surg 1975;56(2):157-165.
4. Gonzalez-Ulloa M: Building out the malar prominences as an
addition to rhytidectomy. Plast Reconstr Surg
1974;53(3):293-296.
5. Brennan HG: Augmentation malarplasty. Arch Otolaryngol
1982;108(7):441-444.
6. Wilkinson TS: Complications in aesthetic malar augmentation.
Plast Reconstr Surg 1983;71(5):643-649.
7. Silver WE: The use of alloplast material in contouring the
face. Facial Plast Surg 1986;3:81-98.
8. Whitaker LA: Aesthetic augmentation of the malar-midface
structures. Plast Reconstr Surg 1987;80(3):337-346.
214
William J. Binder • Brian P. Kim • Babak Azizzadeh
Figure 12-22 Elastic facial dressing. A full face compression garment
can help reduce postoperative edema and fluid collection.

9. Prendergast M, Schoenrock LD: Malar augmentation. Patient
classification and placement. Arch Otolaryngol Head Neck
Surg 1989;115(8):964-969.
10. Binder WJ: Submalar augmentation. An alternative to
face-lift surgery. Arch Otolaryngol Head Neck Surg
1989;115(7):797-801.
11. Terino EO: Alloplastic facial contouring by zonal principles of
skeletal anatomy. Clin Plast Surg 1992;19(2):487-510.
12. Psillakis JM, Rumley TO, Carmargos A: Subperiosteal
approach as an improved concept for correction of the aging
face. Plast Reconstr Surg 1988;82:383.
13. Tessier P: Lifting facial sous-perioste. Ann Chir Plast Esthet
1989;34:193.
14. Ramirez OM: The subperiosteal rhytidectomy: The third-
generation face-lift. Ann Plast Surg 1992;28(3):218-232.
15. Hamra ST: The deep plane rhytidectomy. Plast Reconstr Surg
1990;86:53.
16. Kamer FM: One hundred consecutive deep plane face lifts.
Arch Otolaryngol Head Neck Surg 1996,122:17-22.
17. Chajchir A, Benzaquen I: Liposuction fat grafts in face
wrinkles and hemifacial atrophy. Aesthet Plast Surg.
1986;10(2):115-117.
18. Coleman SR: Facial recontouring with lipostructure. Clin Plast
Surg. 1997;24(2):347-367.
19. Binder WJ, Kaye A: Reconstruction of posttraumatic and
congenital facial deformities with three-dimensional computer-
assisted custom-designed implants. Plast Reconstr Surg
1994;94(6):775-787.
20. Binder WJ, Bloom DC: The use of custom-designed midfacial
and submalar implants in the treatment of facial wasting
syndrome. Arch Facial Plast Surg 2004;6(6):394-397.
21. Broadbent TR, Mathews VL: Artistic relationships in surface
anatomy of the face: Application to reconstructive surgery.
Plast Reconstr Surg 1957;20(1):1-17.
22. Binder WJ: A comprehensive approach for aesthetic
contouring of the midface in rhytidectomy. Facial Plast Surg
Clin North Am 1993;1(2):231-255.
23. Binder WJ, Schoenrock LD, Terino EO: Augmentation of the
malar-submalar/midface. Facial Plast Surg Clinic North Am
1994;2(3):265-283.
24. Rubin JP, Yaremchuk MJ: Complications and toxicities of
implantable biomaterials used in facial reconstructive and
aesthetic surgery: A comprehensive review of the literature.
Plast Reconstr Surg 1997;100(5):1336-1353.
CHAPTER 12
Aesthetic Midface Implants
215

HISTORY
Chin augmentation has been performed using autografts,
alloplastic materials, and mandibular advancement
procedures.1 Autografts are complicated by the need for a
donor site, difficulty with shaping the grafts, and their
unpredictable pattern of resorption.1 In contrast, allo-
plastic implants have proved to be an easy and reliable
means of augmentation. The most common method of
augmentation is with alloplastic implants, including Silastic,
Gore-Tex, Mersilene mesh, and Medpore implants.2-4
Silastic chin implants have the longest history of
continuous use of any of the alloplastic implants. They
have been safely used since the 1960s with a high degree
of satisfaction. Mandibular advancement procedures require
specialized equipment and add significant morbidity to
the procedure with little advantage.
The most significant evolution in mentoplasty has
been in implant design. The earliest Silastic implants were
carved individually by the surgeon. In 1966, Safian and
Dow Corning introduced the first preformed Silastic
implants.1 These implants were equivalent to what is now
referred to as a curvilinear implant or a central implant
without a lateral component. Augmentation was isolated
to the central mentum and provided only an anterior
projection. The most significant advance in implant
design was the introduction of the anatomic style of
implant by Toranto in 1982.5 These types of implants
have lateral tapering extensions, which wrap around the
mandible, providing anterior projection of the mentum,
filling of the prejowl sulcus, and an overall recontouring
of the mandible. The result is a more natural
augmentation of the chin-jawline complex. These
implants are available as either anatomic implants
(McGhan Medical, Santa Barbara, CA) or extended
anatomic implants (Implantech, Ventura, CA). Realizing
the importance of isolated prejowl augmentation in certain
patients, Mittleman introduced his prejowl implant,
which has a thin central portion and bulk only in the
lateral arms.6
The surgical technique for mentoplasty using
alloplastic implants has not significantly changed in
recent years. The two common surgical approaches are an
external technique through a submental incision and an
intraoral technique through a gingivolabial sulcus incision.
Both approaches are commonly used today, generally
determined by the preference of the individual surgeon.
PERSONAL PHILOSOPHY
An optimal facial skeletal structure serves as the
foundation for rhytidectomy and other facial rejuvenation
procedures. Patients with poor skeletal foundations, as
seen with microgenia, will not only tend to show certain
stigmata of aging earlier, such as poor necklines and
jowling, but will also obtain less than ideal results from a
facelift. In the appropriate patients, correction of micro-
genia is a critical technique for facial rejuvenation, either
as a stand-alone procedure or in conjunction with
facelifting (Fig. 13-1).
Alloplastic implantation provides a safe, reliable, and
relatively simple means for chin augmentation. The ideal
implant material should have a very low incidence of
infection or rejection. It should also provide predictable
long-term results and be easy to remove if necessary. In
our practice we use preformed Silastic extended anatomic
implants for augmentation mentoplasty. Silastic implants
meet all the preceding criteria. Silastic implants are
flexible enough to allow for easy insertion and provide a
natural feel and appearance. Silastic is a nonporous
material around which a fibrous capsule forms, allowing
easy removal.7
An extended anatomic implant fills the central
mentum and has lateral arms with sufficient bulk and
extension to fill the prejowl sulcus that taper off laterally
to give a natural jawline. These implants have a lower
incidence of shifting than the central implants. The
extended anatomic implants are usually available in four
sizes, providing between 5 and 9 mm of anterior
projection. As the implant size increases, so does the
length and bulk of the implant’s lateral arms. Several
companies produce this type of implant, but sizing is not
consistent among the different manufacturers.
Central implants do not have a lateral extension to fill
the prejowl sulcus. In patients with preexisting jowls, the
Mentoplasty
Robert A. Glasgold, MD • Mark J. Glasgold, MD • Alvin I. Glasgold, MD
217
C H A P T E R T H I R T E E N

central implant will accentuate the prejowl sulcus, often
making the jowl appear more prominent. This is the
opposite effect of the extended anatomic implant, which,
by filling the prejowl sulcus, will reduce or camouflage the
appearance of a jowl. In patients without jowling, central
implants tend to make the chin appear pointy, again not
producing as attractive an augmentation as the extended
anatomic implant.
When performing a mentoplasty we routinely have a
2-mm Silastic extension wafer available.8 The wafer
provides a degree of intraoperative flexibility in terms of
implant sizing. On intraoperative assessment, if the
patient would benefit from further anterior projection, a
wafer can be placed under the central portion of the chin
implant, increasing anterior central mentum projection by
2 mm. This allows for an increase in anterior projection
while avoiding the added cost and surgical trauma of
replacing the implant with a larger one.
We perform all mentoplasties with an extraoral
approach through a submental incision. In our experience
the submental incision heals very well and allows easier
and more accurate placement of the implant. This is
particularly true when using extended anatomic implants,
which require a lateral subperiosteal pocket along the
inferior mandibular border. This dissection is difficult
through an intraoral approach because of the location of
the mental nerves. The submental approach also allows
for suture fixation of the inferior aspect of the implant to
the periosteum of the inferior border of the mandible,
thereby preventing implant shifting and vertical
migration. Suture fixation ensures the implant is properly
aligned, with no palpable or visible step-off deformity
from implant to mandible. Implants placed through an
intraoral approach are exposed to oral contaminants and
have a greater potential for infection.
ANATOMY
The chin is composed of the overlying skin, subcutaneous
tissues, muscles, and the mandible. Each component
affects the overall appearance of the chin-jawline complex
and its appearance with aging. The muscle components of
the chin are the mentalis, depressor labii inferioris, and
depressor anguli oris muscles, all of which are innervated
by the marginal mandibular branch of the facial nerve.
The mentalis muscle arises from the incisive fossa on the
mandible and inserts inferiorly into the dermis of the
chin. The mentalis muscle acts to elevate the chin. The
depressor labii inferioris and depressor anguli oris
218
Robert A. Glasgold • Mark J. Glasgold • Alvin I. Glasgold
A
B
Figure 13-1 Preoperative (A) and 6-month postoperative (B) views of a patient who underwent mentoplasty with a medium extended anatomic implant
and facelift.

muscles arise from the oblique line of the mandible and
insert into the lip. Together they act to depress the lower
lip and corners of the mouth, respectively.
The portions of the mandible relevant to mentoplasty
are the symphysis, parasymphysis, and the body of the
mandible. Understanding the location of the mental
foramen and mental nerve, which provides sensation to
the chin and lower lip, is crucial. The mental foramen is
generally located inferior to the second premolar.9 If
measured, the foramen is found approximately 2.5 cm
lateral to the midline. The location of the mental foramen
is midway between the alveolar ridge superiorly and the
inferior edge of the mandible. The foramen is found
approximately 1 cm above the inferior border of the
mandible.
The anatomy of this chin-jawline complex changes
with age. Soft tissue and bone atrophy in the central
mentum can lead to or exaggerate the appearance of a
receding chin. Development or exaggeration of a prejowl
sulcus is also due to soft tissue and bone atrophy. Age-
related atrophy of the anterior mandibular groove,
located inferior to the mental foramen, contributes to
the prejowl sulcus.6 Jowling, which also exaggerates the
prejowl sulcus, results from ptosis of skin, muscle,
subcutaneous fat, and buccal fat pad.
PREOPERATIVE ASSESSMENT
Patient evaluation begins with an understanding of what
problems can be corrected with a mentoplasty. These
issues are important for both the older patient seeking
facial rejuvenation and the younger patient desiring an
improved facial appearance. A receding chin produces an
imbalance of the lower third of the face and can be
corrected with a chin implant. Increasing chin projection
will also improve the patient’s appearance on front view,
whereas a weak lower third can give a rounded, less
angular facial appearance. Prominent overprojected lower
lips can be camouflaged by increasing a patient’s chin
projection, thereby creating a more balanced appearance.
Mentoplasty can also aid in creating a stronger jawline by
filling the prejowl suclus.
The most common abnormality of the chin is micro-
genia (retrogenia), which refers to an underprojection of
the chin with normal occlusion. Patients with a receding
chin have a short hyoid-to-mentum distance, which is
usually associated with an obtuse cervicomental angle.
Chin augmentation will improve this relationship by
increasing the distance from hyoid to mentum, giving
the appearance of a more acute cervicomental angle (Fig.
13-2). In the younger patient with submental fullness and
CHAPTER 13
Mentoplasty
219
A
B
Figure 13-2 Preoperative view of a patient with microgenia, displaying a short hyoid-to-mentum distance and a deep prejowl sulcus (A) and six-month
postoperative view following mentoplasty with a medium extended anatomic implant (B).

good skin tone, the addition of submental liposuction can
significantly enhance the result of chin implantation,
creating a more acute cervicomental angle (Fig. 13-3).
The simplest and most practical means to determine
appropriate chin projection on profile is by dropping a
perpendicular line down from the Frankfurt horizontal
which should touch both the lower vermilion and the
pogonion (the anteriormost projection of the chin).
Patients whose projection falls behind this line should
be considered for augmentation mentoplasty. Patients
should also be evaluated while smiling. In a patient with
borderline microgenia, smiling may increase projection to
a degree that augmentation would be inappropriate. The
ideal anterior projection is gender-specific. In women, 1 to
2 mm of underprojection is acceptable, whereas men can
tolerate a slight overprojection, providing a stronger chin.
Malocclusions should be noted and, if present, referred for
orthognathic evaluation.
Development of a prejowl sulcus is a characteristic
sign of aging. In a patient with minimal jowling, filling
the prejowl sulcus with an implant may give a jawline
comparable to that achieved with a facelift. When the
jowl and prejowl sulcus are more prominent, filling the
prejowl sulcus alone will usually be inadequate and a
facelift becomes the primary means of restoring a strong
jawline.
In patients undergoing rhytidectomy for correction of
the jowl, it is important to evaluate whether the prejowl
sulcus will be completely effaced through correction of the
jowl alone. In some patients, the degree of atrophy in the
prejowl sulcus is so significant that rhytidectomy alone
cannot produce the desired jawline. These patients should
be considered for prejowl sulcus augmentation with or
without central mentum projection, depending on their
chin projection on profile (Fig. 13-4).
Patients undergoing mentoplasty should be evaluated
for certain preexisting conditions, any of which, if present,
should be reviewed with the patient so that the patient
is aware of these preoperatively. These conditions include
hypesthesia of the chin and lip region, marginal mandibu-
lar nerve weakness, asymmetries of the chin and jawline,
and contour irregularities of the chin.
Digital photography with computer imaging is helpful
in the evaluation and consultation. Reviewing a patient’s
photograph, particularly on profile, will often help the
patient understand the importance of chin augmentation
for obtaining an optimal result. Computer imaging allows
patients to visualize the effect of augmenting the chin and
filling the prejowl sulcus.
SURGICAL TECHNIQUE
Preoperatively all patients receive intravenous prophylactic
cefazolin or clindamycin, if penicillin allergic. The implant
is prepared by placing a guide suture through each end of
the implant to facilitate its placement and prevent the tail
of the implant from folding upon itself (Fig. 13-5). A 2-0
silk suture threaded onto a Keith needle is passed through
the lateral end of the implant, approximately 3 mm from
the distal edge. This is then repeated with a second 2-0
silk suture and Keith needle for the contralateral side.
Each of the free ends of the 2-0 silk are rethreaded onto
the Keith needle. The implant is then soaked in
clindamycin solution until its placement.
A submental incision, approximately 2 cm in length,
is designed with its medial portion just anterior to the
submental crease and gently curving posteriorly to the
crease at the lateral aspects. The superior skin edge is
retracted upward while dissection is carried down through
the soft tissue and muscle. The periosteum is incised at
the inferior portion of the anterior surface of the
mandible. A cuff of periosteum is preserved at the inferior
border of the mandible, to which the implant is eventually
sutured. A subperiosteal pocket is elevated centrally,
creating a pocket that is large enough to accommodate the
implant. We prefer to elevate the central subperiosteal
pocket using electrocautery.
The lateral subperiosteal pocket is initiated with
electrocautery, hugging the inferior border of the
mandible. A Joseph elevator is introduced to elevate the
subperiosteal pocket (Fig. 13-6). External palpation with
the contralateral hand will help guide the subperiosteal
dissection, ensuring that the pocket remains along the
inferior border of the mandible to avoid trauma to
the mental nerve. Once the pocket is elevated, an Aufricht
retractor (8 × 45 mm) is placed into the pocket (Fig.
13-7). A Joseph elevator is then inserted into the pocket
under the Aufricht retractor and the subperiosteal pocket
is gently stretched to ensure the implant will fit
comfortably into the pocket. The subperiosteal pocket is
then elevated on the contralateral side prior to placing the
implant.
After bilateral subperiosteal dissection is completed,
the Aufricht retractor is used to hold open the pocket. The
Keith needle with guide suture is passed through the
subperiosteal pocket under the retractor, aiming toward
the angle of the mandible, and is passed out through the
skin (Fig. 13-8). The guide suture is grasped by an
assistant and gentle traction is provided to guide insertion
of the implant as it is fed into the pocket with a straight
clamp. The guide suture ensures proper placement of the
lateral tail of the implant, and prevents the thin tail from
folding on itself. Once the implant is inserted and the
Aufricht retractor removed, continued traction is placed
on the guide suture to maintain its position during insertion
of the contralateral side (Fig. 13-9). The Aufricht is now
placed in the contralateral side and the implant inserted
in the same manner as the first side (Fig. 13-10).
Once the implant is inserted its position should be
evaluated both by manual palpation and visual
inspection. Central placement is confirmed by aligning the
220
Robert A. Glasgold • Mark J. Glasgold • Alvin I. Glasgold

CHAPTER 13
Mentoplasty
221
A
B
C
D
Figure 13-3 Preoperative profile (A) and oblique (C) views of a patient with microgenia, a poorly defined jawline, and a prejowl sulcus. One-year
postoperative profile (B) and oblique (D) views after correction with mentoplasty with an extra-large extended anatomic implant and submental liposuction.

222
Robert A. Glasgold • Mark J. Glasgold • Alvin I. Glasgold
Figure 13-4 Preoperative view of a patient with microgenia, heavy jowls, and a deep prejowl sulcus (A): In this patient, mentoplasty provided anterior
chin projection and filling of the prejowl sulcus, the latter of which would have been suboptimally corrected with a facelift alone. One-year postoperative
view following mentoplasty with a medium extended anatomic implant and facelift (B).
Figure 13-6 The lateral subperiosteal pocket is elevated along the
inferior border of the mandible with a Joseph elevator.
Figure 13-5 Extended anatomic implant prepared for placement with
a 2-0 silk suture threaded through each of its lateral ends and onto Keith
needles.
A
B

central blue mark on the implant with the junction of the
upper two central incisors. Manual palpation should
ensure that the implant lies flat against the mandible and
that it is sitting along the inferior border of the mandible.
The degree of anterior projection should be evaluated. It
is important to remember that the intraoperative
appearance can be affected by the swelling from the local
anesthetic and surgical manipulation, as well as the
mandibular recession due to the patient’s supine position.
Positional recession is the more significant concern in
evaluation and is compensated for by holding the jaw in
its proper anatomic position for evaluation.
If further augmentation is deemed necessary after
implant placement, an extension wafer (Glasgold Wafer,
Implantech, Ventura, CA) can be placed to provide 2 mm
of additional anterior projection (Fig. 13-11). The
extension wafer does not have a central mark; making a
nick at its central point on the inferior edge will help
ensure proper alignment. The wafer is then simply
inserted under the central portion of the implant (Fig. 13-
12). Once correctly positioned it is sutured to the chin
implant with two 4-0 polydioxanone (PDS) sutures, each
placed approximately 1 cm lateral to midline.
After it has been confirmed that the implant is
appropriately placed, the implant is sutured to the
inferiorly based cuff of the periosteum with two 4-0 PDS
sutures (Fig. 13-13). These sutures are placed as laterally
as possible. If an extension wafer is used, the 4-0 PDS
suture is placed through the periosteal cuff and then
through both the wafer and overlying implant (Fig. 13-14).
CHAPTER 13
Mentoplasty
223
Figure 13-7 The lateral subperiosteal pocket is exposed with the
Aufricht retractor.
Figure 13-8 Keith needle, with guide suture, being passed through
lateral pocket and out through the skin at the angle of the mandible.
Figure 13-10 Chin implant placed within the subperiosteal pockets.
Figure 13-9 After the implant is fed into the pocket on the right,
traction is maintained on the guide suture to prevent displacement while
inserting the contralateral side.

The muscle is reapproximated over the implant with
interrupted 4-0 PDS sutures. The subcutaneous tissues
are reapproximated with several interrupted 4-0 PDS
sutures. The skin incision is closed with a running 6-0
Prolene suture.
If chin implantation is performed in conjunction with
a facelift, the mentoplasty is performed first. Once the
chin implant is placed and sutured in, the muscle is closed
prior to proceeding with the subcutaneous submental
dissection to address the submental fat and platysma. If
liposuction is performed, it is done first through a small
incision in the center of the planned submental incision
before extending the incision for the mentoplasty.
In some patients, isolated prejowl augmentation is
needed to achieve a straight jawline. Although preformed
implants for prejowl augmentation are available, we
prefer injection augmentation with either autologous fat
or a synthetic filling material. When patients undergoing
a facelift need prejowl augmentation, the fat is harvested
and injected into the prejowl sulcus prior to proceeding
with the facelift at the same setting. For patients who are
having prejowl augmentation as a stand-alone procedure,
this can be done in the office using a local anesthetic.
POSTOPERATIVE CARE
All patients are placed on a 10-day postoperative course
of oral cefadroxil or, if penicillin allergic, clindamycin. No
dressing is used for patients who undergo only mento-
plasty. Patients are instructed to apply ice to the surgical
site. It is not uncommon for patients to complain of
224
Robert A. Glasgold • Mark J. Glasgold • Alvin I. Glasgold
Figure 13-11 Extension wafer (Glasgold Wafer) for use with anatomic
or extended anatomic chin implants to provide an additional 2 mm of
central anterior projection.
Figure 13-12 In cases in which the need for further projection is
determined intraoperatively after implant placement, an extension wafer
can be placed under the central portion of the implant to provide an
additional 2 mm of projection.
Figure 13-13 The implant is secured inferiorly to the mandibular
periosteum with two 4-0 PDS sutures.

postoperative pain; the larger the implant the greater the
tendency for patients to experience discomfort. Patients
are seen on postoperative day 7, at which time the skin
sutures are removed.
COMPLICATIONS
Complications following mentoplasty with alloplastic
implants include infection, over- or undercorrection, asym-
metry, numbness in the distribution of the mental nerve,
marginal mandibular nerve weakness, and mandibular
resorption. Infection is very rare, especially with a sub-
mental approach. It can occur in the immediate post-
operative period as well as months to years later. Infection
usually presents as increasing pain, tenderness, or
swelling. Once the infection is identified, treatment
includes a course of oral antibiotics (amoxicillin-clavulonic
acid or clindamycin). If infection is not resolving with
antibiotics, the implant should be removed. In over
30 years of experience we have had to remove an implant
secondary to infection on only a few occasions. If an
implant is removed because of infection, a period of 6 to
12 months should pass before reimplantation. This allows
sufficient time for swelling to resolve and scar to form so
that sizing for another implant will be accurate.
If the chin appears overprojected during the
postoperative period, the patient should be observed and
reassured over a period of at least 3 months to allow swelling
to subside before deciding to downsize the implant. In the
case of undercorrection, an extension wafer can be placed
under the existing implant as described previously;
alternatively, the implant can be replaced with a larger one.
Asymmetries following augmentation are generally
from a preexisting asymmetrical mandible, which should
have been reviewed with the patient preoperatively.
Implant shifting can occur, and would most commonly be
in the cephalad direction. Shifting is prevented by using
the submental approach, which allows suture fixation of
the implant to the mandibular periosteum.
Numbness and paresthesias in the distribution of the
mental nerve are secondary to traction on the nerve during
surgery and are almost universally self-limited, lasting
from weeks to months. Marginal mandibular weakness is
a very rare temporary complication secondary to traction
on the nerve while the implant pocket is being created.
Bone resorption of the central mandible following
alloplastic chin implants has been described. In practice
this has not been a significant issue.5,10,11 To minimize
resorption, the implant should be placed on the more firm
cortical bone of the lower border of the mandible.10
Placement of the implant in a sub- or superperiosteal
position has not been shown to significantly affect the
incidence of bone resorption.12
Future Considerations
The implants presently available provide a wide range of
options for augmentation, and will likely be used for
many years to come. Autologous fat transfers have been
performed to augment the chin. This technique
minimizes implant-related problems, but provides a less
predictable outcome in terms of anterior projection with
a longer recovery period. Ongoing advances in the field
of injectable filling materials provide a possible alternative
means of chin augmentation. Currently we use these
materials for isolated filling of the prejowl sulcus, but the
possibility exists that improvements may lead to the
ability to achieve a long-term complete chin
augmentation with an injectable material.
REFERENCES
1. Safian J: Progress in nasal and chin augmentation. Plast
Reconst Surg 1966;37:446-452.
2. Adams J: Facial augmentation with solid alloplastic implants.
In Glasgold AI, Silver FH (eds): Applications of Biomaterials
in Facial Plastic Surgery. Boca Raton: CRC Press, 1991.
CHAPTER 13
Mentoplasty
225
Figure 13-14 When an extension wafer is used, the wafer and implant
are first sutured together (the medial sutures). Then the implant and wafer
are secured as a single unit to the mandibular periosteum inferiorly with two
4-0 PDS sutures.

3. Binder W, Kamer F, Parkes M: Mentoplasty—A clinical
analysis of alloplastic implants. Laryngoscope 1981;91:
383-391.
4. McCollough EG, Hom DB, Weigel MT, et al: Augmentation
mentoplasty using mersilene mesh. Arch Otolaryngol Head
Neck Surg 1990;116:1154-1158.
5. Toranto I: Mentoplasty: A new approach. Plast Reconst Surg
1982;69:875-878.
6. Mittleman H: The anatomy of the aging mandible and its
importance to facelift surgery. Facial Plast Surg Clin North
Am 1994;2:301-309.
7. Silver FH, Maas CS: Biology of synthetic facial implant
materials. Facial Plast Surg Clin North Am 1994;2:241-253.
8. Glasgold A, Glasgold M: Intraoperative custom contouring of
the mandible. Arch Otolaryngol Head Neck Surg
1994;120:180-184.
9. Mittelman H: Augmentation of the chin and pre-jowl sulcus.
In Terino EO, Flowers RS (eds): The Art of Alloplastic Facial
Contouring. St. Louis: CV Mosby, 2000.
10. Friedland JA, Coccaro PJ, Converse JM: Retrospective
cephalometric analysis of mandibular bone resorption under
silicone rubber chin implants. Plast Reconstr Surg
1976;57:144-151.
11. Vuyk HD: Augmentation mentoplasty with solid silicone. Clin
Otolaryngol 1996;21:106-118.
12. Pearson DC, Sherris DA: Resorption beneath silastic
mandibular implants. Effects of placement and pressure. Arch
Facial Plast Surg 1999;1:261-264.
226
Robert A. Glasgold • Mark J. Glasgold • Alvin I. Glasgold

HISTORY OF THE TECHNIQUE
Since its introduction into the United States in the early
1980s, liposuction has become the most commonly per-
formed aesthetic procedure.1 Liposuction has been used
from head to toe with reproducible results and minimal
complications. Though the initial experience stemmed
from its applications in body sculpting, suction lipectomy
has become a powerful method to remove undesirable
adipose tissue and to contour the cervicofacial region.
There is currently a wealth of literature documenting
advances in techniques and instrumentation used in
liposuction, and a review of the history of this technique
is important to establish its fundamental principles and
provide a context for evolving applications.2-8
The earliest references to adipose tissue removal date
to the 1920s in France.9 In 1921, Dujarrier removed fatty
tissue from a ballerina’s leg using a uterine curette; this
resulted in amputation secondary to vascular injury and
gangrene. Initial catastrophic results such as this dis-
couraged further attempts at lipoextraction for several
decades. In the early 1970s, Schrudde removed fat for
aesthetic purposes using a uterine curette through a
buttonhole technique, which he called “lipoexeresis.”10
This technique was prone to complications, however, as
large subcutaneous cavities were created, predisposing
patients to seroma formation and irregular skin contours.
Furthermore, as a suction device was not used, constant
irrigation was necessary to remove large segments of adipose
tissue. A more practical approach to lipoextraction was
developed in the mid-1970s by Fischer and Fischer, who
designed a cannula attached to a suction device to facilitate
tissue removal.11,12 A similar approach was independently
developed by Kesselring, who built upon the work of
Schrudde and advocated suction-assisted lipectomy.13
Although the addition of a suction device proved to be
a major advance, problems with sharp-edged curettage
instruments and large cavities created by wide tissue
undermining persisted. Most of these problems were
solved with the advent of the blunt technique, still in use
today. Inspired by the Fischers’ work, Illouz in Paris
reported his 5-year, 3000-case experience with suction-
assisted lipolysis using a new blunt-tipped suction
cannula.14 His “wet technique” included injection of the
aspiration site with a hypotonic saline solution, theo-
retically to rupture the adipocytes. The blunt-tipped
cannulas were connected to a high-power suction machine
and were used to created tunnels in a fan-shaped manner
to aspirate fat.
Fournier made further technical refinements on Illouz’s
technique. He advocated a “dry” technique without pre-
infiltration of hypotonic solution. He did not believe that
infiltration with hypotonic solution was necessary, and his
histologic analysis of aspirated adipose cells treated with
the “wet technique” demonstrated that there was, in fact,
no cellular disruption. Furthermore, Fournier proposed
taping the suctioned areas to collapse the aspiration
tunnels and advocated the idea of syringe liposuction as
an alternative to suction pumps.15
American surgeons visited France and learned the
techniques of liposuction. In 1977, the first American to
visit France was Field, a dermatologic surgeon.16 Other
American surgeons followed, and in 1980, Martin, an
otolaryngologist, visited Illouz and began to perform lipo-
suction in Los Angeles in 1981. Soon, symposia and
training courses were held to disseminate the techniques
of liposuction. The American Society of Plastic and
Reconstructive Surgeons was primarily under the tutelage
of Illouz, whereas Fournier was largely responsible for
encouraging participation and teaching physicians from
all specialties. The first American course in liposuction
was given by Newman, an otolaryngologist and cosmetic
surgeon, and Dolsky, a plastic surgeon, in Philadelphia in
1982. Since that time, there has been great intellectual
dialogue and innovation, leading to significant advances
in cannula instrumentation, aspiration methods, lipo-
shaving, and anesthetic techniques.
PERSONAL PHILOSOPHY
Facial liposuction has revolutionized facial aesthetic surgery
by allowing surgeons to contour and improve anatomic
regions that were not adequately addressed previously;
indeed, liposuction has become an integral technique in
the successful rejuvenation of the face. The authors
recognize that many excellent aesthetic surgeons differ in
the nuances of their liposuction techniques. This chapter
Facial Suction Lipectomy
Jeannie H. Chung, MD • Edwin F. Williams III, MD, FACS
227
C H A P T E R F O U R T E E N

does not attempt to provide an impartial treatise on facial
suction lipectomy, but rather provides a practical strategy
born of significant clinical experience to produce optimal
results.
Of the overall population undergoing facial lipo-
suction, the authors find that only a select group of
patients benefit from primary facial liposuction alone.
Such primary liposuction procedures are reserved for
younger patients with localized adipose tissue and good
skin tone, which allow for adequate skin contracture and
redraping. In the authors’ experience, facial suction
lipectomy is frequently used in conjunction with other
facial rejuvenation procedures (e.g., mentoplasty, plas-
tysmaplasty, or rhytidectomy) and is most effective in
recreating an acute cervicomental angle.
Although the tunneling technique is frequently used
to remove adipose collections in the submental region, the
authors prefer the “layer technique” in which a skin flap
is elevated prior to aspiration (Fig. 14-1). The authors
find that this technique facilitates excellent skin redraping
without the risk of dimpling and skin irregularities from
septal attachments inherent in the tunneling technique.
Liposuction has traditionally been described as being
performed by the “open” versus “closed” technique. In
the open technique, skin is elevated to expose the fatty
tissue layer, which is then removed under direct vision
with the cannula. In the closed technique, multiple
tunnels are created with the cannula, through which fat is
suctioned blindly. While the distinction between these
different methods is important academically, the authors
find that these differences are often blurred in practice.
In all surgical endeavors, the authors strive for
straightforward and safe techniques. For many aesthetic
procedures, new instruments, equipment, and technology
are being introduced to facilitate use, improve results, and
minimize complications. However, these advancements
need to be evaluated with a critical eye. At its most
fundamental level, suction lipectomy involves a rigid
cannula connected to a suction device. New technology,
such as the liposhaver and ultrasound-assisted liposuction
228
Jeannie H. Chung • Edwin F. Williams III
Figure 14-1 Schematic representation of the layer technique for liposuction. The skin is widely undermined in the subcutaneous plane (A), which allows
for uniform retraction of the skin after liposuction (B). With the tunneling method, random passes are created with the aspiration cannula (C), creating a
greater risk of dimpling and uneven skin contours as the skin retracts (D).
A
C
B
D

(UAL), has been used in efforts to improve on the removal
of undesirable adipose tissue. Although these techniques
are reviewed in this chapter, the authors have had success
with “traditional” time-tested techniques and feel encum-
bered with unneeded gadgetry. One does not need to
engage in the newest technique or purchase the most
modern equipment to have excellent results.
Although liposuction techniques in the face and neck
have been used for other indications such as lipomas and
defatting of skin and myocutaneous flaps, this chapter
focuses specifically on its cosmetic applications. This
chapter provides preoperative guidelines for proper patient
selection, reviews options for anesthesia, highlights
necessary equipment, and outlines salient technical points.
ANATOMY
A thorough understanding of facial anatomy is critical to
the successful application of lipectomy techniques. A
comprehensive review of the head and neck is beyond the
scope of this chapter, but it is important to highlight the
anatomic structures and landmarks relevant to facial
liposuction. Although various regions have been
addressed with liposuction (Fig. 14-2), the most common
area of concern for patients remains the neck. Cervical
anatomy has many variations, and the specific anatomic
features pertinent to aesthetic appearance merit special
attention. These considerations are critical in performing
appropriate preoperative evaluation and tailoring the
ultimate surgical approach.
The portion of the neck that is best addressed by lipo-
suction is the central subunit, which is bounded supe-
riorly by the inferior border of the mandible, posteriorly
by the anterior border of the sternocleidomastoid muscle,
and inferiorly by the thyroid cartilage. Beneath the skin
lies a variable amount of fat. The quality of this fat varies
from patient to patient as well as from one anatomic
region to another. The adipose layer lies superficial to the
platysma, a thin broad-based muscle that originates from
the superficial fascia over the pectoral and deltoid
muscles, ascends over the clavicle, and inserts on the
mandible below the oblique line and the skin at the lateral
angle of the mouth. The posterior and superior borders
extend in continuity with the superficial muscu-
loaponeurotic system (SMAS). Significant variation may
exist in the midline of the platysma, from the mentum to
the hyoid bone. In some patients, the muscle fibers
decussate across the midline, creating a muscular sling. In
others, the absence of decussation may lead to a diastasis
that worsens over time. Rejuvenation of the neck requires
manipulation of one or more of these structures. It is
important to note that optimal results following lipo-
suction depend as much upon the resiliency and elasticity
of the overlying skin as the amount of fat removed.
Liposuction is usually performed in the adipose layer
superficial to the platysma, an extremely safe region
devoid of vital neurovascular structures. However, the
surgeon will occasionally need to remove deeper layers of
adipose tissue or dissect deep to the platysma to mobilize
its medial ends (i.e., platysmaplasty). These maneuvers
warrant extreme caution given the risk of injury to the
deep neurovascular structures. The anterior jugular veins
and perforating branches of the submental vascular plexus
lie deep to the platysma, near its midline. If violated, they
may be difficult to control, particularly with limited
exposure and visualization. The marginal mandibular
branch of the facial nerve is also at risk when liposuction
is directed over the mandible. The marginal mandibular
nerve courses inferiorly, anterior to the angle of the
mandible, 1 to 2 cm below the inferior margin of the
mandible into the submandibular triangle. The nerve then
ascends over the mandible to innervate the depressor
muscles of the mouth 2 cm lateral to the oral commissure.
Although the marginal mandibular nerve lies under the
cover of the platysma, some patients may have attenuated
muscle fibers; aggressive suctioning for jowls and
mandibular contouring may place this nerve at risk of
inadvertent injury.
In 1980, Ellenbogen described five visual criteria that
create the appearance of a youthful neck.17 These criteria
are (1) a distinct mandibular border without jowl overhang,
(2) a subhyoid depression, which gives the appearance of
a long and thin neck, (3) a visible thyroid cartilage contour,
(4) a visible anterior border of the sternocleidomastoid
muscle, and (5) a cervicomental angle measuring between
105 and 120 degrees (Fig. 14-3). These criteria were
CHAPTER 14
Facial Suction Lipectomy
229
E
F
D
C
B
A
Figure 14-2 Common cervicofacial regions for liposuction include the
lateral neck (A), submandibular and submental triangles (B), jowl pad (C),
parotid, buccal, and malar areas (D, E), and preantrum (F).

initially used to assess the results of platysma cervical
lifts, but they are also applicable in the more global
assessment of the neck. Not all of these criteria may be
attainable with liposuction, but they serve as useful
guidelines for the goals of surgical treatment.
PREOPERATIVE ASSESSMENT
As with any cosmetic procedure, success depends on
patient selection and careful preoperative evaluation. At
the first consultation, the surgeon should investigate the
patient’s motivation for surgery and expectations regarding
its outcomes. Patients who believe that a change in their
appearance will dramatically alter their personal or
professional lives are bound for disappointment. The
psychological profiles of these patients make them poor
candidates for surgical intervention. It is imperative that
the surgeon and patient be in accord regarding the goals
of treatment.
A full medical history should also be assessed to
evaluate the appropriateness of surgical intervention and
to identify risk factors for suboptimal results. Comor-
bidities such as hypertension, coagulopathies, diabetes,
and smoking may complicate healing in the postoperative
period. Patients with significant weight gain are not good
candidates for local liposuction, as it is not a cure for
overall obesity. However, liposuction is effective for
patients who are plagued with unwanted local deposits of
fat, which may be a result of hereditary predisposition,
poor dietary and exercise habits, age, medications,
hormones, or weight gain. Even when weight loss regimens
are implemented, facial areas such as the submental
region are difficult to change. Though exercise programs
help to tone muscles throughout the body, it is difficult to
strengthen muscles of the face and neck; in addition,
toned muscles do not necessarily reduce the amount of
superficial adipose tissue. Hereditary predispositions of
local fat accumulations are especially difficult to address.
Although the mechanism of adipocyte hyperplasia is
unknown, it has been previously assumed that a stable
number of adipocyte cells existed after puberty. Newer
evidence suggests that new adipocytes may be formed
with excessive weight gain to store excess lipids.18
Although most weight gain is handled by the enlargement
of existing adipocytes, excessive gain strains adipocytes to
a critical mass and stimulates the formation of new fat
cells.19 With diet and weight loss, lipid content of cells may
be reduced, but the number of adipocyte cells remains
constant.20 Liposuction is the only medical approach known
to decrease the number of adipocytes.
A critical anatomic and aesthetic evaluation is essential
for proper patient selection. A systematic approach will
prevent the surgeon from overlooking any critical anatomic
features and from making an erroneous assessment of the
locus of concern. Evaluation should start with an
assessment of the patient’s overall body habitus. Patients
of short and stocky stature with wide necks will not achieve
a thin, contoured neck even with significant liposuction
(Fig. 14-4).
The surgeon must then assess the following:
1. Skin condition. Skin should be evaluated for
flexibility, elasticity, firmness, and adherence to the
underlying tissues, all of which play a critical role in
predicting outcomes.21,22 Skin with elastic integrity
will more effectively redrape over the underlying
liposuctioned contour. Dedo suggested that skin
contractility may be suboptimal in patients older
than 40 years old and Gryskiewicz found that a
crepe paper appearance of the skin was the best
preoperative predictor of failure from isolated
liposuction without rhytidectomy.2,22
2. Amount and location of fat. The surgeon should
assess the location and amount of fat by palpation.
This is best accomplished with the pinch and roll
technique.2,3 The skin should be palpated or rolled
between two fingers to determine the thickness of
the skin and fat. In the cervical region, the presence
230
Jeannie H. Chung • Edwin F. Williams III
Figure 14-3 Five visual criteria for a youthful neck as described by
Ellenbogen: distinct mandibular line (1), subhyoid depression (2), thyroid
cartilage bulge (3), anterior border of the sternocleidomastoid muscle (4),
and a cervicomental angle between 105 and 120 degrees (5). (From
Ellenbogen R, Karlin JV: Visual criteria for success in restoring the youthful
neck. Plast Reconstr Surg 1980; 66(6):826-837.)

of preplatysmal fat should be differentiated from
subplatysmal fat. With palpation, subplatysmal fat
is generally firmer owing to its connective tissue and
fibrous content.2
3. Integrity of the platysma. The surgeon should
evaluate the thickness and laxity of the platysma.
The presence of platysmal bands at rest indicate
that some form of platysmaplaty should be per-
formed for proper rejuvenation of the neck.3,8
Furthermore, cervical liposuction may expose occult
bands.23 This may be assessed by having patients
strain their neck with their teeth clenched while
making a grimace; with this provocative test,
platysmal bands due to laxity of the muscular
anterior borders may be revealed.
4. Condition of the surrounding skeletal frame-
work. Deficiencies in the surrounding skeletal frame-
work of the cervicofacial region may significantly
affect the results of liposuction. Both Dedo and
Kamer devised classification systems evaluating
cervical abnormalities to guide preoperative
evaluation and selection of the most appropriate
surgical option.22,24 Dedo proposed that patients
with either a short mandible-to-hyoid distance or
low-lying hyoid have an obtuse cervicomental angle,
limiting the effects of submental surgery (Fig. 14-5).
Correct projection of the mentum will give the
impression of an acute cervicomental angle. To better
assess this, the surgeon may drop a plumb-line
CHAPTER 14
Facial Suction Lipectomy
231
down from the lower lip. In women, the mentum
should be at or slightly behind this line when viewed
from the lateral aspect. In men, the mentum should
be on or slightly anterior to this line.
5. Prominence of surrounding soft tissue struc-
tures. The surgeon should assess for ptotic subman-
dibular or large parotid glands. Liposuction in the
submandibular region may enhance the appearance
of the submandibular glands.2,23 Similarly, lipo-
suction of cheek fat may enhance the anterior
border of an enlarged parotid gland. Furthermore,
patients with heavy masseter musculature may not
benefit from facial liposuction.
After a thorough physical evaluation has been
performed, the surgeon determines if a patient is an
appropriate candidate for isolated liposuction. The ideal
patient for isolated liposuction has good skin elasticity, is
of stable and average weight, and has a localized adipose
collection out of proportion to the rest of the body.
Some patients are not good candidates for isolated
liposuction and would benefit from adjunctive procedures.
Without offending patient sensibilities, the surgeon must
recommend the procedure(s) likely to provide the most
benefit. Obviously, the surgeon should make recom-
mendations in light of the patient’s area of concern. For
example, augmentation mentoplasty is a wonderful
adjunct to cervical liposuction in creating the appearance
of an acute cervicomental angle. However, most patients
Figure 14-4 Preoperative lateral view of a 42-year-old woman with a short, wide neck, low-lying hyoid bone, and thick, heavy skin (A). She has excess
adipose tissue in her central neck with significant blunting of the cervicomental angle. Postoperative view at 6 months following liposuction through
submental and infra-auricular incisions (B). Although the patient has some improvement in her neck, her intrinsic neck anatomy, skin texture, and the
presence of substantial subplatysmal fat prevent an optimal result from liposuction alone
A
B

do not seek consultation with a surgeon for a chin
implant; rather, they ask for improvement in their neck
contour, and it is only when the advantage of an implant
is pointed out that patients realize the benefits. Older
patients need to be counseled that liposuction alone will
not improve the appearance of aging skin or facial wrinkles.
These patients may benefit from other rejuvenative
procedures such as rhytidectomy or skin resurfacing.
Preoperative clinical photographs and documentation
are essential. Frontal, oblique, and lateral views should be
taken in the Frankfurt plane against a solid background.
Photographs are critical for preoperative planning and
equally important for documentation. Some patients may
not fully appreciate the postsurgical results until they are
reminded of their preoperative appearance. Computer
imaging may also be useful during initial consultation
and preoperative assessment. It allows the surgeon to
communicate through a tangible medium and illustrate
the benefits of adjunctive procedures such as augmen-
tation mentoplasty. Furthermore, computer imaging may
confirm that the patient’s vision of the postoperative result
coincides with that of the surgeon. In all things, it is the
responsibility of the surgeon to use computer imaging in a
judicious and forthcoming manner.
At the conclusion of the consultation, the surgeon
offers his or her opinion on the aesthetic procedure(s) that
would best address the patient’s area of concern. The
surgeon then counsels the patient on realistic outcomes
to prevent postsurgical disappointment and provides a
detailed review of the expected postoperative course to
allay apprehension and anxiety. Such communication and
open dialogue will facilitate a smooth perioperative course.
SURGICAL TECHNIQUE
The goals of facial suction lipectomy are to remove
unwanted deposits of fat and to create a smooth contour.
Although these goals seem straightforward, several
technical nuances need to be appreciated to avoid
complications and to provide optimal surgical results.
Although the techniques are similar to those used in body
contouring, the surgeon needs to be cognizant of the
anatomic and aesthetic considerations specific to the
facial region. The thin nature of facial skin and the close
proximity of the marginal mandibular nerve leave little
room for error in the aggressive reduction of fat. With
meticulous attention to technique and adherence to the
fundamental principles mentioned previously, facial
liposuction may achieve successful results with a low rate
of morbidity.
EQUIPMENT
A reliable aspiration device is inherent to successful
liposuction. Multiple suction devices are commercially
available, but the most effective and efficient machines
share several characteristic features. Although perfect
vacuums (1 atm, 760 mm Hg, 29.92 inches Hg) are
difficult to achieve in the clinical setting, suction devices
that are able to achieve vacuums close to 29 inches Hg
are the most desirable. Low noise output (<55 DbA scale)
and high flow rate (>100 L/min) are also desired
features.21 In the cervicofacial region, vacuum pressures
of 22 to 23 inches Hg are usually adequate for smooth
and continuous suction. The surgeon should check the
232
Jeannie H. Chung • Edwin F. Williams III
Figure 14-5 The hyoid bone should ideally rest
cephalad and posterior to the mentum for a youthful neckline
(A). A low-lying anterior hyoid bone limits the results of
submental liposuction and cervical rejuvenation (B).
A
B

suction pressure prior to the start of any procedure to
ensure that the pressure is within the desired range.
Handheld syringe liposuction, popularized by
Fournier, is also a safe and efficient alternative to suction
pump fat removal.15 Fournier believed this method
minimized blood loss and provided the surgeon with
accurate measurements of the amount of fat removed.
Furthermore, the potential for cross-contamination is
eliminated because a common suction device is not
employed. Syringe liposuction is also an excellent backup
should there be mechanical or electrical problems with a
suction pump.
Other features of suction devices that facilitate ease of
use include operator control of the vacuum pressure,
whether by foot switch or finger-controlled release. This
allows the surgeon to prevent unintentional removal of fat
as the cannula is withdrawn. Current suction models also
have filters between the disposable canister and pump to
prevent biohazardous contamination.
In addition to a reliable suction source, appropriate
cannulas should be chosen. An abundance of cannulas are
currently available (Fig. 14-6). The surgeon will typically
become familiar with three or four cannulas that he or
she will use routinely, depending on the location and
phase of liposuction (e.g., active fat removal, sculpting,
or feathering). In the cervicofacial region, most frequently
used cannulas range in size from 1 mm (microcannulas)
to 6 mm in diameter. Larger cannulas have the capacity
to remove greater volumes of fat and are appropriate for
areas such as the submental triangle. However, micro-
cannulas are useful for fine sculpting and contouring,
particularly in areas near vital neurovascular structures,
such as the marginal mandibular nerve. Microcannulas
are frequently used to contour the jowls, cheeks, and
nasolabial folds.
Cannulas with blunt tips are preferable in the cervi-
cofacial region. Blunt cannulas have openings located a
few millimeters away from the tip and are gentler on the
tissues than those designed with end openings. Cannulas
with the opening at the tip may act as a shaver when
passed over tissue and may function more as a curette
than a gentle suction device. The spatula-shaped tip is
useful for undermining skin flaps in the preplatysmal and
preparotid fat, as their shape allows the surgeon to stay
superficial to the platysma and parotid fasciae. The flat
shape also creates a better seal on the tissue. However,
these cannulas may become easily obstructed.
Cannulas are manufactured with varying numbers of
apertures (Fig. 14-7). Those with more openings allow fat
to be suctioned more rapidly. We prefer a cannula with a
single suction aperture for active fat removal, though
multiple apertures are useful on the microcannulas to
facilitate fat removal through a smaller diameter lumen.
There are also cannulas that may be attached to the
handle via a Luer-Lok connection, which are more
economical than those permanently attached to handles
(Fig. 14-8). The Luer-Lok system also allows cannulas to
be attached to aspiration syringes for syringe liposuction.
Finally, Luer-Lok microcannulas may be attached to
small syringes and are useful in autologous fat injection.
MARKINGS
It is prudent in the preoperative holding area to mark the
patient while in the upright position, as the soft tissue
contours may become distorted when the patient lies
supine. Important anatomic structures, such as the
inferior border of the mandible, anterior and posterior
borders of the sternocleidomastoid muscle, superior
border of the thyroid cartilage, course of the marginal
mandibular nerve, and external jugular veins, are marked
CHAPTER 14
Facial Suction Lipectomy
233
Figure 14-6 Liposuction cannulas are available in a variety of lengths,
diameters, and tip specifications.
Figure 14-7 Aspiration cannulas with different tip shapes, aperture
sizes, and numbers allow versatility in their function and in the areas to
receive suction lipectomy. The cannula on the far right is suitable for
infiltration whereas the spatula tip cannula (second from right) is useful on
the adipose tissue overlying the parotid and buccal regions. The cannula on
the far left has its opening at the tip of the cannula rather than the side which
allows it to remove fat through a shaving mechanism.

(Fig. 14-9). Furthermore, submental fat, jowl pads, and
other fat deposits are also marked. One approach utilized
alternating cross-hatches to distinguish between the main
areas to be treated versus the adjacent areas to be
feathered. Markings for any planned adjunctive pro-
cedures may be placed at this time. Even with careful
preoperative marking, tissues may become distorted on
the operating table with changes in position, edema, and
local infiltration; for this reason, it may be useful to have
preoperative photographs available during the procedure.
ANESTHESIA
Several options for anesthesia are available, depending on
physician and patient preference. Traditionally, facial
plastic surgeons and plastic surgeons have been trained to
perform surgical procedures in the operating room with
general anesthesia or intravenous (IV) sedation. For isolated
facial suction lipectomy, IV sedation usually suffices. When
adjunctive procedures are performed, general anesthesia
may be used. Local nerve blocks to the infraorbital,
mental, and transverse cervical nerves may also be used to
provide peri- and postoperative anesthesia.
Our dermatology colleagues have advanced the frontier
of office-based procedures using local anesthetic techniques.
In 1987, Klein introduced the tumescent technique, allowing
the safe administration of larger doses of lidocaine.25 The
recommended maximum dose of lidocaine was 7 mg per
kilogram of body weight when given with epinephrine.
Klein showed that lidocaine could be safely given up
to 35 mg/kg if diluted in large volumes of hypotonic
fluid (Table 14-1), as decreasing the concentration of
lidocaine resulted in slower peak plasma levels. Another
advantage with tumescence is decreased blood loss.26,27
The tissue bed is bathed in the tumescent fluid for at
least 15 minutes, allowing prolonged vascular exposure to
epinephrine.
For office-based liposuction with tumescence,
patients may be given 1 mg of oral diazepam and 25 mg
of intramuscular meperidine prior to the procedure.
Proper monitoring is necessary if additional IV sedation is
given. The entry site for the liposuction cannula is then
infiltrated with 1% lidocaine mixed with 1:100,000
epinephrine, and a microcannula used for infiltration is
placed through a small incision. The microcannula is sub-
234
Jeannie H. Chung • Edwin F. Williams III
A
B
Figure 14-8 The Luer-Lok mechanism allows an interchangeable
system whereby various aspiration cannulas may be used with a single
handle. With a typical Luer-Lok handle (A), the cannulas attach at one end
(left) and the suction tubing at the other (right). The same Luer-Lok cannulas
may be attached to a syringe for syringe liposuction (B).
A
B
Figure 14-9 Preoperative markings on a three-quarters view of the
important neurovascular structures (marginal mandibular nerve and
external jugular vein) and landmarks (sternocleidomastoid muscle,
mandibular border, and thyroid notch) (A). A system of different markings
helps delineate areas of greatest fat accumulation (diagonal lines) and areas
to be feathered (stippling in B).

sequently connected to an IV bag containing the
tumescent fluid (Fig. 14-10). In this fashion, the micro-
cannula may be used to simultaneously create tunnels in
the adipose tissue and deliver the tumescent fluid. Once
the requisite 15 minutes has passed to allow for adequate
vasoconstriction and anesthesia, liposuction may be
performed.
Although tumescent anesthesia has a strong following
among those with office-based practices, the authors prefer
IV sedation for facial contouring. Tumescence offers a
significant advantage when used for body contouring, as
volumes up to 2000 mL of adipose tissue may be
removed; however, typical volumes of fat removed in the
cervicofacial region do not usually exceed 150 mL. Even
though some proponents feel that tumescence facilitates
dissection in the proper tissue planes, the authors find
that the resultant tissue distortion makes assessment
difficult and hinders precise facial contouring.
TECHNIQUE
Most areas of the face and neck can be accessed during
primary liposuction through a combination of small
incisions. The most common approaches are submental,
pretragal, infralobular, postauricular, and intranasal.
These incisions are well hidden and well tolerated by the
patient. The choice of incisions depends on the site(s) to
be treated.
Primary liposuction has been used to contour the
submentum, lateral neck, jawline, melolabial folds, and
midface. In our experience, the majority of patients who
benefit from isolated liposuction seek improvement in the
appearance of their necks. The ideal patient for
submental liposuction is the younger patient with
localized fat and resilient skin, devoid of platysmal
pathology (Fig. 14-11). Optimal results depend as much
on the ability of the skin to rebound and redrape as on the
amount of fat that is removed.
The tunneling method initially developed by the
Fischers is used by many facial plastic surgeons. Although
the authors do not routinely utilize the tunneling
technique in the submental region, it does incorporate
fundamental techniques applicable in many parts of the
face and neck. This technique is useful in areas of
minimal fat where skin flap elevation would not be
beneficial (e.g., the melolabial folds, facial lipomas). The
tunneling technique for the submental region is outlined
here.
Submental liposuction begins with an incision that is
made 1 mm posterior to the submental crease. Proper
incision placement is essential to prevent deepening of this
crease with subsequent scar contracture, a deformity that
is likened to a “witch’s chin.” The incision is typically 1
cm in length to accommodate a 4- to 6-mm cannula. The
incision should be large enough to accommodate the
cannula with additional space to prevent friction burn on
the wound edges from the back-and-forth motion of the
cannula. The incision is carried through the skin and
subcutaneous adipose tissue, and 1 to 2 cm of the
surrounding skin is elevated sharply using small Iris or
tenotomy scissors. This creates a tissue pocket, which
facilitates placement of the cannula tip in the appropriate
subdermal plane. The cannula is then introduced with the
aperture directed toward the adipose tissue and away
from the skin flap. During cannula insertion, the suction
should be off to prevent inadvertent injury to the adjacent
skin.
Once the cannula tip has been safely introduced
beneath the skin, interconnecting tunnels are created
radially from the mentum to the anterior borders of the
sternocleidomastoid muscle laterally and the thyroid
notch inferiorly, similar to spokes radiating from the
center of a bicycle wheel (Fig. 14-12). Some surgeons
advocate pretunneling without suction to facilitate
dissection in the proper plane. After the tunnels are
created in the region of the planned liposuction, suction is
CHAPTER 14
Facial Suction Lipectomy
235
Table 14-1
Klein’s Tumescent Formula for Liposuction*
Component
Amount
Lidocaine
50 mL of 1% lidocaine solution
(500 mg)
Epinephrine
1 mL of 1:1000 solution of
epinephrine solution (1 mg)
Sodium bicarbonate
12.5 mL of 8.4% NaH2CO3
solution
Normal saline
1 L of 0.9% NaCl solution
*For cervical liposuction, a 500 mL bag of normal saline suffices. The
amount of the components must be adjusted accordingly.
From Klein JA: Tumescent technique for liposuction surgery. Am J
Cosmet Surg 1987;4:263-267.
Figure 14-10 A model of a tumescent infusion pump with adjustable
flow rates and a foot pedal (not shown), which allows the surgeon to
control infiltration.

applied and multiple passes are re-executed in the same
spoke-like fashion. The right-handed surgeon should
control the cannula with the right hand while the left
hand constantly folds the skin over the cannula. This
maneuver will help to assess the depth of the cannula tip
as well as the thickness of the adipose layer. Throughout
the procedure, the surgeon pauses and palpates the neck
and target areas to ensure a smooth, even contour. Bulges
and irregularities indicate uneven liposuction; dimpling
connotes tethering of the septal attachments, which
should be released. As the submentum lies in the center of
the “spokes,” care should be taken to ensure even
aspiration. Hollowing and a submental depression may
occur if too much liposuction is performed in this region.
The tunnels created by this method allow the superficial
tissues to compress into the newly created dead space.
Another proposed advantage of this technique is the
preservation of septal attachments from the subcutaneous
tissue to the dermis above. These septa contain blood
vessels and nerves, and their preservation ensures
continued vascular and nervous supply to the skin.28
Furthermore, these attachments are believed to aid in the
contracture of overlying skin.
Although many surgeons espouse the tunneling
technique, contracture of the septal attachments between
the tunnels may result in dimpling and skin irregularities.
The authors currently use the layer technique for the
submental region to minimize the possibility of uneven
skin contours.29 The initial steps are identical to those
outlined previously. Once the area around the submental
incision is dissected in the proper plane, wide double-
hook retractors are used to retract the superior and
inferior skin flaps for proper tensioning. The right-
handed surgeon typically stands at the head of the bed
and holds the inferior retractor with the left hand. The
assistant stands on the right side of the bed while holding
the inferior retractor. Rather than creating dry tunnels
with a cannula, the surgeon widely undermines the sub-
mental region to the anatomic borders mentioned above
with Metzenbaum scissors (Fig. 14-13). Undermining
should not proceed over the mandible in efforts to prevent
injury to the marginal mandibular nerve. At least 3 to
4 mm of adipose tissue should be left on the underside of
the skin flap to prevent an uneven contour and to preserve
the skin’s vascularity. Wide undermining also allows
excellent redraping of skin without tethering from septal
attachments and the consequent skin irregularities. The
authors have not had any problems with long-term
dysesthesias or vascular compromise of skin flaps in their
patients.
Once the skin flaps have been widely elevated, the
liposuction cannula is passed evenly across the expanse of
236
Jeannie H. Chung • Edwin F. Williams III
A
B
Figure 14-11 An ideal candidate for isolated submental liposuction with localized fat and resilient, elastic skin (A). Notable improvement could be seen
in her neck contour, 6 months following submental liposuction (B).

CHAPTER 14
Facial Suction Lipectomy
237
tissue. The suction aperture should always face the deeper
tissue, as aspiration of the skin flap may lead to dermal
scarring. As in the tunneling technique, the surgeon uses
the nondominant hand to fold the skin over the cannula
tip, assessing the depth of adipose tissue (Fig. 14-14). To
prevent a demarcation between the treated and untreated
areas, undermining should extend beyond the aspiration
site and feathering should be performed at the perimeters.
Although the authors do not advocate sharp
lipectomy on a routine basis, direct excision may be used
in select situations. Some patients have persistent midline
adipose deposits even after suction lipectomy has been
performed. These patients benefit from careful direct
lipectomy, but direct excision may result in a submental
depression if performed in an overly aggressive manner.
The medial borders of the platysma may also be identified
during direct lipectomy when a concomitant plastysmaplasty
is planned.
Even after broad liposuction and direct excision,
some patients have persistent submental fullness due to
subplatysmal fat. Although suction lipectomy has been
performed for subplatysmal fat, the authors do not
routinely advocate this practice, as the subplatysmal plane
is replete with submental vessels and the risk of bleeding
is significant. Bleeding in the subplatysmal plane may be
brisk and obtaining control of the bleeding with limited
Figure 14-12 Submental liposuction is performed in a systematic
fashion from a submental incision (A and B). The submentum serves as a
fulcrum from which the cannula is advanced in a radial fashion, like the
spokes of a wheel, to the anterior borders of the sternocleidomastoid
muscle laterally, and the thyroid notch inferiorly. Caution must be exercised
not to advance the tip of the cannula deep to the platysma muscle to
prevent inadvertent injury to the deep structures of the neck.
A
B
Figure 14-13 In the layer technique, the skin flap is widely undermined
with Metzenbaum scissors across the submental region to just inferior (1 to
2 cm) to the jawline. Dissection is carried in a subcutaneous plane to the
anterior borders of the sternocleidomastoid muscle and thyroid notch, with
the tip of the scissors tenting the skin upward to prevent injury to the
deeper structures of the neck. Sharp dissection should not be carried
directly over the mandible to protect the marginal mandibular nerve.
Placement of a double-hook at the incision provides counter-retraction on
the skin flap.

exposure and visualization using electrocautery places the
marginal mandibular nerve at risk.
The jowls, lateral neck, and submandibular regions
may be approached from postauricular or infralobular
incisions (Fig. 14-15). The jowl is an unforgiving area for
contour irregularities. When contouring the jowl, the
cannula may extend to the oral commissure anteriorly
and the margin of the mandible inferiorly. Thus, smaller
cannulas (1 to 2 mm) are useful for delicate sculpting and
creating a smooth transition with nonaspirated regions.
Suction should be released upon withdrawal from the jowl
to prevent inadvertent aspiration of tissue in the posterior
facial tissue and creation of an unsightly divot. If a small
volume of fat is to be removed, occasional release of the
vacuum allows the fat to reach the collection canister. In
this way, the surgeon may accurately assess the amount of
fat that has been removed. The postauricular or
infralobular incisions also provide excellent access to the
submandibular area and allow overlap with the areas
aspirated via the submental approach.
The prominent melolabial fold continues to be a
challenge. Liposuction can be used to contour this region
and begins with a small incision placed in the nasal
vestibule. An incision may also be made in the nasolabial
groove but risks a visible scar. A 1-mm cannula is placed
through the incision, and tunnels are created in an arc-
like fashion from the prominence of the fold to the antral
fat. The authors do not routinely treat the melolabial folds
primarily with liposuction, as the results are variable and
often transient.30,31 However, when performed to com-
plement another procedure, such as rhytidectomy, lipo-
suction of the melolabial fold may add to the overall
improvement of the face.32
Lipocontouring alone may be inadequate for many
patients seeking rejuvenation of the neck. Liposuction will
not benefit patients with lax skin or platysmal banding.
Liposuction is frequently combined with platysmaplasty
for neck recontouring in these cases. The platysmaplasty
may be performed after liposuction is completed, allowing
the surgeon visualization of the platysma. Using a head-
light and a converse retractor, the surgeon may evaluate
the integrity of the platysma. The medial edges are lifted
with forceps. If laxity exists, the medial strip of platysma
is sharply resected. If there is wide separation between the
medial edges, a long fine-pronged hemostat is used to
undermine the platysmal edges to facilitate subsequent
closure. Again, caution is exercised any time dissection is
carried deep to the platysmal layer to prevent injury to the
submental vascular plexus. Furthermore, any dissection
or resection of muscle will increase the likelihood of bleeding.
A long-handled bipolar forceps and suction should be
available to obtain hemostasis. Backcuts are made on the
platysma at the level of the cervicomental angle to
decrease blunting of the angle from realignment of the
238
Jeannie H. Chung • Edwin F. Williams III
Figure 14-14 The surgeon drapes the skin over the cannula aperture
with his or her nondominant hand to guide the passage of the cannula as
well as to constantly assess the depth of adipose tissue. The cannula
aperture should be directed away from the skin flap to prevent dermal
scarring and contour irregularities. The cannula tip also helps tent the skin
flap to prevent inadvertent injury to deeper structures.
Figure 14-15 Cervicofacial liposuction may be achieved through a
limited number of incisions. The submental incision allows excellent access
to the central neck. The lateral neck and jowls may be approached from the
infra- or retroauricular incisions, and the preauricular incision allows
liposuction over the parotid bed and midface region. An incision in the nasal
vestibule or nasolabial groove is used for the melolabial folds.

medial edges of the platysma muscle. The medial edges
of the exposed platysma muscle are reapproximated with
a running 4-0 polydioxanone suture (PDS, Ethicon,
Somerville, NJ; Maxon, US Surgical/Davis and Geck,
Norwalk, CT) starting at the point superior to the back
cuts. The incision is closed with a 6-0 polypropylene suture,
placed in a running, interlocked fashion. Some have
advocated the use of synthetic fibrin sealant on the
superficial layer of the platysmal muscle followed by
pressure for 5 minutes to aid with hemostasis and
adhesion of the skin flap to underlying muscle.3
Concomitant chin augmentation may significantly
enhance the results of submental liposuction in some
patients (Fig. 14-16). The chin implant places anterior
stretch on the cervical skin, creating a tighter cervico-
mental angle. In the preoperative assessment, patients
with microgenia should be identified, and the benefits of a
chin implant discussed. The chin implant should be
placed after submental liposuction has been completed to
accurately assess the projection of the implant. Implan-
tation may be performed using the same submental
incision described above. Some patients with microgenia
may also have an occlusal deformity, most commonly a
class II occlusion. The addition of a chin implant will not
correct an occlusal mismatch, and this should be
discussed with the patient preoperatively.
Liposuction may be combined with rhytidectomy to
optimize aesthetic results (Fig. 14-17). This combination
effectively removes undesirable collections of fat, high-
lights natural angles and contours of the face and neck,
and removes redundant skin. Submental liposuction and
platysmaplasty are such integral components of lower
facial rejuvenation that they are practically considered
part of complete rhytidectomy.33 Submental liposuction
and platysmaplasty usually precedes rhytidectomy. Even
in lean necks that do not require submental liposuction,
undermining of cervical skin promotes favorable skin
contracture.33 After liposuction, direct assessment and
treatment of the platysma is possible. Plastysmaplasty
only enhances neck contour when combined with
posterior pull of the SMAS. Obviously, if a patient
presents for a short-flap facelift (S-lift) for minimal jowl
formation, submental liposuction and platysmaplasty are
not indicated. After the submental incision is closed,
attention is turned to the rhytidectomy.
The authors begin with a standard rhytidectomy
incision. Skin flaps are elevated and facial liposuction is
performed after SMAS plication. Other types of rhytidec-
tomy (e.g., SMAS imbrication, deep-plane rhytidectomy)
may be performed, depending on surgeon preference, and
these techniques are further discussed in other chapters in
this textbook. A 4-mm spatula-tip cannula may be used
to aspirate fat from the pretragal region, jowl, and
midface under direct vision (Fig. 14-18). In this manner,
“cross-hatching” may be performed evenly to prevent
overtreatment of any one area. A small 1-mm cannula is
used for fine contouring over the jowl. Through the
rhytidectomy incision, the lateral neck and the
submandibular region may also be aspirated. This
provides overlap with the central neck areas treated from
the submental incision and promotes a smooth, overall
contour. A “cobra” deformity, which may arise if the
central neck receives aggressive liposuction, may thus be
avoided.
The importance of a proper postoperative dressing
cannot be overstated. A pressure dressing assists in
decreasing edema, reducing the risk of hematoma
formation, and allowing the skin to adhere to the under-
lying musculature. Equally important, a pressure dressing
aids in the proper draping of the skin. A host of dressings
are commercially available. Whichever is selected, it
should be adjustable and comfortable (Fig. 14-19). Foam
padding may also be used beneath the dressing to apply
evenly distributed pressure on the surgical site. The pres-
sure dressing is worn continuously for 1 week, followed by
2 to 4 weeks of additional nighttime wear.
Recently, there has been interest in applying ultra-
sound technology to techniques of liposuction.5,34,35 Based
upon the physics of sound transmission, ultrasonic energy
may be targeted to specific tissues according to differences
in tissue density. Denser tissues, such as tendons, liga-
ments, and skin, contain more collagen and elastin and
are resistant to fragmentation when subjected to ultra-
sound treatment. Conversely, ultrasonic energy is more
readily absorbed by less dense parenchymal tissues, such
as adipose.36 This results in both micromechanical
disruption and cavitation of adipose tissue. In microme-
chanical disruption, ultrasonic waves affect intracellular
components, leading to progressive structural rearrange-
ments and ultimately cell death. Cavitation refers to the
effect of the oscillatory activity of vapor-filled bubbles or
microneuclei within cells. Ultrasound causes micronuclei
to expand until a critical size is reached, at which time
they implode, causing cell membrane disruption and
diffusion of fatty acids into the extracellular matrix. Of these
two phenomena, cavitation results in more significant
tissue destruction, which results in easier fatty aspiration.
Clinically, ultrasonic energy may be delivered internally
through a cannula or by external application. Studies
have found little benefit of external ultrasonic liposuction
(XUAL) over traditional liposuction techniques.37,38
Conversely, the advantage of internal ultrasound-assisted
liposuction is well documented in areas of high fibrous
content.34,39,40 Although UAL confers an advantage for
body contouring in areas of high fibrous content and
larger volumes of fat, these are not usually concerns in the
cervicofacial region.
Proponents of UAL assert that that this technology
offers additional advantages in the cervicofacial region.
Ultrasonic energy stimulates an inflammatory response in
the skin, causing it to retract. Some believe that this
retraction is greater than that achieved with traditional
CHAPTER 14
Facial Suction Lipectomy
239

240
Jeannie H. Chung • Edwin F. Williams III
C
D
A
B
Figure 14-16 Preoperative (A) and 6-month postoperative (B) lateral and preoperative (C) and 6-month postoperative (D) oblique views of a 25-year-
old patient with submental fullness, microgenia, and elastic skin who underwent submental liposuction and Gore-Tex chin augmentation. The chin implant
serves as an excellent adjunct to submental liposuction by placing anterior stretch on the skin, resulting in a tighter cervicomental angle.

liposuction.5 Thus, ultrasound advocates believe that UAL
may accomplish more than what can be achieved by
suction lipectomy alone, particularly in patients with more
advanced signs of aging. Furthermore, internal ultra-
sound is thought to remove superficial fat more readily
and more evenly, as the probe approaches the subdermal
fat internally and thus reduces the risk of avulsion.
Ultrasonic energy delivered internally facilitates lipo-
suction through the emulsification and evacuation of fat.
Pretunneling is performed, followed by the introduction
of the ultrasound probe. The surrounding fat is emul-
sified, and a suction cannula is used to evacuate the emul-
sified fat, which takes on the consistency of a creamy
liquid. The end point is reached when resistance is
encountered from the overlying skin collapsing down into
the cannula.
Internal ultrasonography, however, poses several
inherent dangers. Given the proximity of the probe to the
overlying dermis, extreme caution is recommended to
prevent thermal injury to the skin or neurovascular
embarrassment.41,42 The probe should be used with constant
motion in a consistently moist environment. Although
many studies have enumerated the dangers of thermal-
related injuries from internal ultrasonography, no large
controlled studies have been performed comparing the
CHAPTER 14
Facial Suction Lipectomy
241
A
B
Figure 14-17 Preoperative lateral view (A) of a 64-year-old patient who was primarily concerned with the appearance of her neck. Submental liposuction
alone would not significantly improve the cervicomental angle given the laxity and inelasticity of her skin. Postoperative lateral view (B) at 4 months following
submental liposuction, rhytidectomy, and endoscopic brow/midface lift with notable improvement in her cervicomental angle.
Figure 14-18 Liposuction over the parotid bed, jowls, and midface
region may be facilitated under direct vision through the facelift incision. The
authors prefer to elevate the rhytidectomy skin flaps in the traditional
manner with sharp dissection, followed by liposuction. However,
pretunneling may be performed initially with or without suction to facilitate
skin flap elevation.

safety or efficacy of this technique to traditional suction
lipectomy. As with the introduction of any new tech-
nology, the surgeon must develop appropriate experience
and comfort to ensure comparable results and patient
safety. Finally, the costs for new equipment and additional
operative time should be taken into consideration.
The soft tissue shaving procedure has been introduced
as another alternative to conventional liposuction. Soft
tissue shaving, touted by some to be more precise and less
traumatic, is based upon a completely different mech-
anism of soft tissue extraction. The liposhaver is thought
to be less traumatic because it utilizes lower suction
pressures and does not rely on the back-and-forth move-
ments for fat extraction. Instead, current liposhavers
utilize an oscillating cutting blade within a blunt cannula,
which cuts tissue immediately adjacent to the blade and
subsequently extracts it with low suction. The liposhaver
may also be used as a conventional liposuction cannula
with lower vacuum pressures. Soft tissue shavers have
been used since the 1970s for removal of acoustic
neuromas and have subsequently been employed for
endonasal polypectomy and orthopedic arthroscopic
surgery. In 1995, Gross and associates introduced
liposhaving for facial plastic surgery.43 Since then, the
liposhaver has been utilized to remove fat from the
submental region, beneath the facelift flap, and for the
nasolabial folds via the submental, facelift, or intranasal
incisions, respectively.43-45 Multi-institutional studies have
demonstrated that liposhaving contours fat evenly
without dimpling or asymmetry.44,45 These studies also
established the safety profile of these techniques, with
particular reference to facial nerve injury and post-
operative hematoma formation. However, meticulous
technique is critical, as the liposhaver can incise muscle
and other soft tissues. The surgeons in the multi-
institutional studies maintain that the light touch without
firm pressure was critical in avoiding injury to the
platysma. Most surgeons preferred the open approach
with this device because of increased precision and safety.
POSTOPERATIVE CARE
Patients benefit from receiving a detailed description of
their planned postoperative course prior to any procedure.
Written information is helpful, and these instructions
serve to minimize apprehension about their appearance
and postoperative care. Patients are seen on the first
postoperative day, when their pressure dressing is
removed. The surgical site is inspected for hematoma, and
the skin flaps are examined for proper redraping. If the
skin flap is not properly redraped, gentle digital pressure
and sweeping may serve to redirect the skin. Local wound
care should be performed with the application of
hydrogen peroxide and topical antibiotic ointment to the
incisions. The pressure dressing is then reapplied, and
patients are instructed to wear the compression garment
continuously for 1 week. At 1 week, the submental sutures
may be removed. The compression garment is then worn
nightly for up to 4 additional weeks. Younger patients
may require less time with the compression dressing, as
youthful elastic skin will adhere and redrape more quickly
than in older patients.
Patients should be counseled that postoperative
edema may take months to resolve completely. Proper
preoperative counseling will avoid confusion of typical
postoperative swelling for failure to change the pre-
operative contour. Diligent use of the compression
garment will hasten the resolution of edema. Ecchymosis
and discoloration may also take up to 2 weeks to resolve.
As postoperative swelling diminishes, subtle submental
contour irregularities may appear; these typically soften
and dissipate over time. Postoperative antibiotics are
usually unnecessary unless a chin implant was placed.
Postoperative discomfort is usually minimal.
COMPLICATIONS
Long-term experience with facial suction lipectomy has
shown it to be a safe surgical modality with relatively few
242
Jeannie H. Chung • Edwin F. Williams III
Figure 14-19 A large pressure dressing with cotton batting may be
used on the first postoperative day following facial suction lipectomy, but a
lighter pressure dressing as pictured above is worn continuously thereafter
for 1 week, and then nightly for an additional 2 to 4 weeks to facilitate skin
draping and to reduce postoperative swelling. This dressing is elastic,
reusable, and adjustable with Velcro straps.

complications. Unlike whole-body liposuction, facial
liposuction does not have the capacity to produce major
fluid shifts typically seen with removal of large quantities
of adipose tissue. Furthermore, even though bleeding can
be brisk in the face and neck, blood loss is usually of
negligible consequence and certainly much less than in
body liposuction. Hematoma and seroma formation is
rare (<1%) and may usually be evacuated by needle
aspiration and pressure dressing.46 A rapidly expanding
hematoma, however, requires exploration and drainage
in the operating room. Although primary infections occur
in less than 1% cases, infections occurring in existing
hematomas should be managed aggressively.47 Fortu-
nately, most reported cases of facial nerve neuropraxia
are transient palsies arising from contusion or stretch
injuries and resolve within a few weeks.8,48 The marginal
mandibular nerve is the most commonly affected,
followed in frequency by the buccal branches of the facial
nerve.
Other complications may result from overzealous
liposuction. In the neck, aggressive liposuction may
expose platysmal bands not previously apparent, creating
a “cobra” deformity (Fig. 14-20). This may require
platysmaplasty to correct. Conservative aspiration in
the face will reduce the risk of “skeletonizaton,” a phe-
nomenon which may not be appreciated in the immediate
postoperative period but which may become more
pronounced with advancing age and subsequent loss of
facial volume. When significant, the hollowed areas may
be augmented with autologous fat injections. Misguided
aspiration of the skin flap may result in dermal scarring
with limited options for correction.
Contour irregularities and asymmetries may manifest
once edema resolves. One study reported that 10% of
patients were undertreated, necessitating touch-up
treatments.2 Touch-up liposuction may be performed in
the office under local anesthesia with microcannulas.
Corticosteroid injections may also be used to induce fat
atrophy for subtle areas too small for microcannula
aspiration. This technique should be used conservatively,
with 1 to 3 mg triamcinolone acetate solution injected at
4- to 6-week intervals for 2 to 3 months. Overtreatment
will result in dermal atrophy and depression as well as the
formation of spider telangiectasias.
Future Considerations
Liposuction has experienced tremendous growth in
popularity since the 1980s. It is now widely accepted as
an effective and safe method of removing undesirable fat.
In addition, though liposuction was initially developed for
aesthetic purposes, its applications have expanded
beyond the realm of cosmetic surgery. Liposuction has
been used to remove lipomas49 and to recontour bulky
myocutaneous and cutaneous flaps via minimally invasive
techniques.50 Indeed, some have proposed using
liposuction as a treatment for obesity-associated
metabolic abnormalities, such as high plasma levels of
glucose, insulin, and lipids; however, recent data show
that reducing adipose tissue mass alone will not achieve
the same metabolic benefits as weight loss.51 Liposuction
has also been advocated as a treatment for
gynecomastia,52 hyperhidrosis,53 and upper extremity
lymphedema for breast cancer patients following
mastectomy and axillary node dissection.54 Further
research is needed to substantiate these and other
proposed applications. Certainly the next decade will
continue to see much change in the field of liposuction
as has occurred since its introduction to the United States
in 1982. The prospects for noncosmetic applications are
exciting, though more clinical and basic science research
needs to be done. It is our hope and expectation that
with continued innovation, liposuction will increasingly
improve the quality of life for our patients.
REFERENCES
1. American Society for Aesthetic Plastic Surgery Statistics,
2003, accessed at
CHAPTER 14
Facial Suction Lipectomy
243
Figure 14-20 Platysmal bands were unmasked in this patient after
aggressive liposuction and subdermal scarring is evident from poor
technique of liposuction on the underside of the skin flap.

2. Gryskiewicz JM: Submental suction-assisted lipectomy without
platysmaplasty: Pushing the (skin) envelope to avoid a face
lift for unsuitable candidates. Plast Reconstr Surg
2003;112(5):1393-1405; discussion 1406-1407.
3. Fattahi TT: Management of isolated neck deformity. Atlas
Oral Maxillofac Surg Clin North Am 2004;12(2):261-270.
4. Guerrerosantos J: Liposuction in the cheek, chin, and neck: A
clinical study. Facial Plast Surg 1986;4(1):25-34.
5. Grotting JC, Beckenstein MS: Cervicofacial rejuvenation using
ultrasound-assisted lipectomy. Plast Reconstr Surg
2001;107(3):847-855.
6. Schaeffer BT: Endoscopic liposhaving for neck recontouring.
Arch Facial Plast Surg 2000;2(4):264-268.
7. Goodstein WA: Superficial liposculpture of the face and
neck. Plast Reconstr Surg 1996;98(6):988-996; discussion
997-998.
8. Knize DM: Limited incision submental lipectomy and
platysmaplasty. Plast Reconstr Surg 2004;113(4):1275-1278.
9. Coleman WP: The history of dermatologic liposuction.
Dermatol Clin 1990;8:381-383.
10. Schrudde J: Lipoexeresis as a means of eliminating local
adiposity. International Society of Aesthetic Plastic Surgery.
New York: Springer-Verlag, 1980;4:215-226.
11. Fischer A, Fischer G: First surgical treatment for molding
body’s cellulite with three 5 mm. incisions. Bull Int Acad
Cosmet Surg 1976;3:35.
12. Fischer A, Fischer G: Revised techniques for cellulites fat
reduction in riding breeches deformity. Bull Int Acad Cosmet
Surg 1977;2:40.
13. Kesselring UK, Meyer R: A suction curette for removal of
excessive local deposits of subcutaneous fat. Plast Reconstr
Surg 1978;62(2):305-306.
14. Illouz YG: Body contouring by lipolysis: A 5-year experience
with over 3000 cases. Plast Reconstr Surg 1983;72(5):
591-597.
15. Fournier PF: Why the syringe and not the suction machine?
J Dermatol Surg Oncol 1988;14(10):1062-1071.
16. Flynn TC, Coleman WP II, Field LM, et al: History of
liposuction. Dermatol Surg 2000;26(6):515-520.
17. Ellenbogen R, Karlin JV: Visual criteria for success in restoring
the youthful neck. Plast Reconstr Surg 1980;66(6):826-837.
18. Billings E Jr, May JW Jr: Historical review and present status
of free fat graft autotransplantation in plastic and
reconstructive surgery. Plast Reconstr Surg 1989;83(2):
368-381.
19. Krotkiewski M, Bjorntorp P, Sjostrom L, et al: Impact of
obesity on metabolism in men and women. Importance of
regional adipose tissue distribution. J Clin Invest
1983;72(3):1150-1162.
20. Vasselli JR, Cleary MP, Van Itallie TB: Modern concepts of
obesity. Nutr Rev 1983;41(12):361-373.
21. Hetter GP: Improved results with closed facial suction. Clin
Plast Surg 1989;16(2):319-332.
22. Dedo DD: Management of the platysma muscle after open and
closed liposuction of the neck in facelift surgery. Facial Plast
Surg 1986;4(1):45-56.
23. Morrison W, Salisbury M, Beckham P, et al: The minimal
facelift: Liposuction of the neck and jowls. Aesthet Plast Surg
2001;25(2):949-9.
24. Kamer FM, Lefkoff LA: Submental surgery. A graduated
approach to the aging neck. Arch Otolaryngol Head Neck Surg
1991;117(1):40-46.
25. Klein JA: The tumescent technique for liposuction surgery. Am
J Cosmet Surg 1987;4:263-267.
26. Klein JA: Tumescent technique for regional anesthesia permits
lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg
Oncol 1990;16(3):248-263.
27. Klein JA: The tumescent technique. Anesthesia and
modified liposuction technique. Dermatol Clin 1990;
8(3):425-437.
28. Teimourian B, Kroll SS: Subcutaneous endoscopy in suction
lipectomy. Plast Reconstr Surg 1984;74(5):708-711.
29. Kesselring UK: Facial liposuction. Facial Plast Surg
1986;4(1):1-4.
30. Velazquez JM: Improving the labial commissurae and
paralabial folds with minimally invasive procedures: A useful
method for midfacial rejuvenation. Aesthet Plast Surg
2004;28(2):100-107.
31. Guyuron B, Michelow B: The nasolabial fold: A challenge, a
solution. Plast Reconstr Surg 1994;93(3):522-529; discussion
530-532.
32. McKinney P, Cook JQ: Liposuction and the treatment of
nasolabial folds. Aesthet Plast Surg 1989;13(3):167-171.
33. Williams EF, Lam SM: Comprehensive facial rejuvenation.
Philadelphia: Lippincott Williams & Wilkins, 2004.
34. Omranifard M: Ultrasonic liposuction versus surgical
lipectomy. Aesthet Plast Surg 2003;27(2):143-145.
35. Graf R, Auersvald A, Damasio RC, et al: Ultrasound-assisted
liposuction: An analysis of 348 cases. Aesthet Plast Surg
2003;27(2):146-153.
36. Lawrence N, Coleman WP 3rd: The biologic basis of ultrasonic
liposuction. Dermatol Surg 1997;23(12):1197-1200.
37. Lawrence N, Cox SE: The efficacy of external ultrasound-
assisted liposuction: A randomized controlled trial. Dermtatol
Surg 2000;26(4):329-332.
38. Cardenas-Camarena L, Cardenas A, Fajardo-Barajas D:
Clinical and histopathological analysis of tissue retraction in
tumescent liposuction assisted by external ultrasound. Ann
Plast Surg 2001;46(3):287-292
39. Cardenas-Camarena L, Andino-Ulloa R, Mora RC, et al:
Laboratory and histopathologic comparative study of internal
ultrasound-assisted lipoplasty and tumescent lipoplasty. Plast
Reconstr Surg 2002;110(4):1158-1164; discussion 1165-
1166.
40. Rohrich RJ, Morales DE, Krueger JE, et al: Comparative
lipoplasty analysis of in vivo-treated adipose tissue.
Plast Reconstr Surg 2000;105(6):2152-2158; discussion
2159-2160.
41. Igra H, Satur NM: Tumescent liposuction versus internal
ultrasonic-assisted tumescent liposuction. A side-to-side
comparison. Dermatol Surg 1997;23(12):1213-1218.
42. Howard BK, Beran SJ, Kenkel JM, et al: The effects of
ultrasonic energy on peripheral nerves: Implications for
ultrasound-assisted liposuction. Plast Reconstr Surg
1999;103(3):984-989.
43. Gross CW, Becker DG, Lindsey WH, et al: The soft-tissue
shaving procedure for removal of adipose tissue. A new, less
traumatic approach than liposuction. Arch Otolaryngol Head
Neck Surg 1995;121(10):1117-1120.
44. Becker DG, Cook TA, Wang TD, et al: A 3-year multi-
institutional experience with the liposhaver. Arch Facial Plast
Surg 1999;1(3):171-176.
45. Becker DG, Weinberger MS, Miller PJ, et al: The liposhaver in
facial plastic surgery. A multi-institutional experience. Arch
Otolaryngol Head Neck Surg 1996;122(11):1161-1167.
46. Jasin ME: Submentoplasty as an isolated rejuvenative procedure
for the neck. Arch Facial Plast Surg 2003;5(2):180-183.
47. Kridel RWH, Pacella BL: Complications of liposuction. In
244
Jeannie H. Chung • Edwin F. Williams III

Eisele D (ed): Complications of Head and Neck Surgery.
St. Louis: Mosby-Year Book, 1992, pp 791-803.
48. Tapia A, Ferreira B, Eng R: Liposuction in cervical
rejuvenation. Aesthet Plast Surg 1987;11(2):95-100.
49. Al-basti HA, El-Khatib HA: The use of suction-assisted
surgical extraction of moderate and large lipomas: Long-term
follow-up. Aesthet Plast Surg 2002;26(2):114-117.
50. Mowlavi A, Brown RE: Suction lipectomy during flap
reconstruction provides immediate and safe debulking of the
skin island. Ann Plast Surg 2003;51(2):189-193.
51. Klein S, Fontana L, Young VL, et al: Absence of an effect of
liposuction on insulin action and risk factors for coronary
heart disease. N Engl J Med 2004;350(25):2549-2557.
52. Gasperoni C, Salgarello M, Gasperoni P: Technical refinements
in the surgical treatment of gynecomastia. Ann Plast Surg
2000;44(4):455-458.
53. Atkins JL, Butler PE: Hyperhidrosis: A review of current
management. Plast Reconstr Surg 2002;110(1):222-228.
54. Brorson H: Liposuction in arm lymphedema treatment. Scand
J Surg 2003;92(4):287-295.
CHAPTER 14
Facial Suction Lipectomy
245