Facial Liposculpture

Jason Haack, M.D.1 and Oren Friedman, M.D.1,2

ABSTRACT

Modern advances in rejuvenation of the aging face have minimized morbidity and
recovery time and maximized natural aesthetic results. Liposuction and autologous fat
transfer techniques have emerged as popular methods to achieve these ends. Used alone, or
in conjunction with other modalities, lipocontouring will likely continue to play a
prominent role in facial aesthetic and reconstructive surgery.

KEYWORDS: Aging face, aging neck, neck rejuvention, lipocontouring face

Downloaded by: University of Florida. Copyrighted material.

F acial aesthetic surgery has increased in popularity
over the past decades. Improvements in techniques to
suspend the superficial musculoaponeurotic system and
adjacent fat pads have evolved so that there is little mor-
bidity and great reliability. Liposculpture of the head and
neck may complement aging face surgery or it may be used
independently for defined areas of facial rejuvenation.
Modern trends in facial sculpting are expanding the
long-time practice of fat transfer to achieve ideal aesthe-
tic results with minimally invasive techniques.1
The principles of blunt suction-assisted lipectomy
were developed in Europe in the late 1970s and later
became known as liposuction.2 These techniques were
first used for volume reduction but evolved to include
body sculpting.3 Cosmetic surgeons began applying
these principles to the neck and jowls for facial rejuve-
nation through minimal access incisions.4 Additional
advances have included endoscopic ultrasound lipectomy
and the use of liposhavers. Today, facial sculpting
focuses on repositioning of fat pads and augmenting
facial transition zones. This is accomplished through
internal suspension sutures and slings, as well as with
autologous fat grafting.
ADIPOCYTE
Knowledge of the basic concepts of adipose tissue is
essential for safe and reliable liposculpture. At age 25,
the total body fat content in a male is 15% and in a
female is 25%. As individuals age, the adipocyte may
change through hypertrophy or hyperplasia.5
Fetal fat is believed to develop from early fibro-
blasts and appears during the fourth month of gestation.
Most adipocyte deposits convert from multilocular, or
brown adipose tissue, to the more familiar white uni-
locular adipose tissue by birth. These cells are roughly
25% the size of adult adipocytes. The number of fat cells
triples during the first year and increases once again at
puberty.5 Studies by Van and colleagues identified that
adipocyte precursor cells were still present in adulthood
and that these cells could be stimulated to become
mature adipose cells with weight gain.6,7
At the cellular level, adipose tissue is composed
of adipocytes contained within a connective tissue
matrix. The lipid content within a single adipocyte is
variable from one cell to another. The connective tissue
is composed of collagen and elastin fibers, as well as
macrophages, fibroblasts, pericytes, and mast cells. An
aggregation of individual fat cells with their accompa-
nying vascular supply is termed ‘‘lipid lobule.’’8
Weight gain within an individual to a moderate
level of obesity occurs through lipid accumulation and
hypertrophy of individual cells. Average cell weights are
0.4 mg and can attain masses up to 1.0 mg. As an
individual gains weight in excess of 40 kg of body fat, new
fat cells form from immature precursors to accommodate

1
Department of Otorhinolaryngology, Mayo Clinic, 2Department of
Otorhinolaryngology, Mayo Medical School, Rochester, Minnesota.
Address for correspondence and reprint requests: Oren Friedman,
M.D., Director, Facial Plastic and Reconstructive Surgery, Department
of Otorhinolaryngology, Mayo Clinic, 200 1st Street SW, Rochester,
MN 55905.
Modern Surgery of the Aging Face; Guest Editors, Adam T. Ross,
M.D., Jeffrey B. Wise, M.D.
Facial Plast Surg 2006;22:147–153. Copyright # 2006 by Thieme
Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001,
USA. Tel: +1(212) 584-4662.
DOI 10.1055/s-2006-947721. ISSN 0736-6825.
147
148 FACIAL PLASTICS SURGERY/VOLUME 22, NUMBER 2 2006
the excess lipid accumulation. This hyperplastic adipose
deposition is believed to be permanent and resistant to
subsequent dieting. Although the adipose cell size may be
reduced by reduction of lipid content, the number of
newly formed cells will remain constant.5 After maximal
reduction of adipocyte size, the only method to reliably
reduce fat content is by excision.
PATIENT SELECTION
Proper patient selection combined with meticulous
technique will ensure satisfactory aesthetic results. Pa-
tient selection relies upon the surgeon’s understanding of
what liposculpture can achieve and upon detailed pre-
operative facial analysis. It is essential to match the
chosen intervention with the needs of the patient and
to establish realistic expectations for the patient.
Facial regions that are often treated with lip-
osuction include the submentum, lateral neck, jowls,
nasolabial fold, and buccal areas. Areas of excess tissue
laxity and gravitational descent do not respond well to
liposuction and therefore need to be distinguished from
areas of excess fat, which can be well managed with
liposuction. One method to evaluate the degree of excess
skin laxity and the need for a rhytidectomy is the Illouz
test. The distance between the earlobe and menton is
measured. The skin is then pulled away from the face
and the distance is measured a second time. If the
difference between the two measurements is less than
15%, a lipectomy technique may be all that is necessary.
If the difference is greater than 20%, a formal rhytidec-
tomy may be indicated.9
Skin elasticity must always be taken into con-
sideration. After pulling on the skin, the surgeon
should evaluate how well the skin rebounds. If the
skin rebounds well, the patient is likely to be a good
candidate for liposculpture. Once fat is removed, the
highly elastic skin will nicely appose the underlying
bony structures to restore the appearance of a youthful
mandibular line.
To appropriately analyze the neck, the surgeon
asks the patient to grimace, whistle, and smile. While
maintaining the grimace pose, the presence and degree
of platysmal banding can be appreciated.10 If the pla-
tysma is flat, broad, and even, liposuction alone will
provide a smooth rejuvenated appearance. If platysmal
banding is evident, management of the platysma with
tightening techniques may be necessary.11 An ideal
cervical mental angle ranges from 105 to 120 degrees.
A low-set hyoid bone may create a more obtuse angle,
making minimally invasive neck surgery less effective.
If the submandibular glands are large or ptotic, a
facelift must be considered. A pinch test may be useful to
evaluate submental fat thickness. In general, fat super-
ficial to the platysma is more easily grasped and manip-
ulated than fat deep to the platysma. A suggested
minimum thickness of adipose tissue is between three-
eighths and one-half inch.10 The jowls are a common
area of both excess adipose tissue and excess skin laxity.
Careful palpation and oblique traction of the cheek can
help to define this anatomic region. The nasolabial folds
may also be evaluated with simple upward traction. If a
prominent nasolabial fold is significantly improved with
elevation, it is unlikely that liposuction will give long-
lasting results. If noticeable bulges are still present with
traction, liposuction may be a viable option.10
OVERVIEW OF MODERN LIPOSUCTION
TECHNIQUES
Aspirin and other blood thinning agents should be
discontinued at least 10 days prior to surgery. Preoper-
atively, the areas of the face to be treated are marked
prior to injection of any local anesthetic to avoid soft
tissue distortion secondary to the infiltrative anesthetic.
A basic clear skin preparation solution is used to sterilize
Downloaded by: University of Florida. Copyrighted material.
the field.
Lipocontouring may be performed under local,
monitored local, or general anesthesia. Lidocaine (1%)
with 1:100,000 epinephrine may be used in conjunction
with hyaluronidase to prevent ecchymosis and promote
diffusion of the anesthetic. The area of planned inter-
vention is infiltrated. A broad area may be reached with
the use of a spinal needle.12 Sedation can be safely
achieved with the use of midazolam, propofol, and
occasionally fentanyl.
Liposuction removes excess subcutaneous adipose
tissue and initiates skin contracture. Access to the sub-
cutaneous tissue is through 3- to 4-mm skin incisions,
which allow for cannula insertion. Common incision
locations include the submental crease, preauricular
crease, postauricular hairline, and lateral hairline.
Liposuction cannulas range in size between 2 mm and
6 mm, with most cannulas possessing a blunt end with a
lateral opening.
Cannulas are passed in a subcutaneous plane as
negative pressure is applied. The rapid motion of the
cannula shears the subcutaneous fat from the surround-
ing soft tissue, and the suction delivered through the
cannula port removes it from the field of dissection. The
external skin is directly visualized and palpated during
this process to ensure correct depth and location of fat
removal. The lateral port of the cannula is maintained
away from the surface of the skin to prevent excessive
thinning and puckering of the skin. A few millimeters of
superficial fat are left in place to facilitate an even
contour and preserve vascular supply. The cannula
should feather slightly past the preoperative markings
to blend treated with untreated zones.
At the conclusion of the procedure the small entry
wounds are closed with absorbable suture. A compressive
dressing is placed over the treated area for 24 to 48 hours.

SITE-SPECIFIC TECHNIQUES IN HEAD
AND NECK LIPOSUCTION
The most common facial area treated with liposuction
is the preplatysmal adipose tissue. Access points are
generally through submental and postauricular inci-
sions (Fig. 1). A crisscross technique is advocated to
create a smooth natural appearance to the neck. This
allows for the creation of a more acute cervicomental
angle and the reduction of soft tissue laxity caused by
the presence of excess fat (Fig. 2). Overaggressive
liposuction should be avoided to prevent a sunken
indentation in the neck.3
Access to the jowls at the mandibular border can
be achieved through the submental approach, as well as
through either a preauricular or postauricular incision
(Fig. 3). Dissection superficial to the platysma avoids
injury to the marginal mandibular nerve.
The melolabial fold can be difficult to access and
good results are difficult to achieve. As the malar fat pad
becomes ptotic with age, the melolabial folds are accen-
tuated. They may give the appearance of a separate fat pad,
when none may be present. Access is most often achieved
through a sublabial or lateral nasal incision. A 2- or 3-mm
cannula should be used with minimal fat removal. Over-
resection may create the unappealing likeness to a ‘‘de-
flated balloon’’ and the patient may appear more aged.10
Removal of the malar fat pad has been met with
mixed results. Ptotic midface tissues that give a sunken
appearance to the cheeks and eyes are often best treated
with repositioning of the fat pads and with autologous
fat augmentation.
TUMESCENT TECHNIQUE
High-volume fluid injection prior to liposuction has
been titled the ‘‘tumescent technique.’’ Klein has pio-
FACIAL LIPOSCULPTURE/HAACK, FRIEDMAN 149
neered this method of local anesthesia and tissue infil-
tration.13,14 Formulation of local anesthetic includes
500 to 1000 mg of lidocaine, 0.5 mg of epinephrine,
10 mEq sodium bicarbonate, and 1 to 2 L of physio-
logical saline. This is injected through a spinal needle in
the subcutaneous fat. Multiple access points are created
and microcannulas (inner diameter of less than 2 mm)
are used to crisscross the treated areas. Decreased blood
loss, minimal trauma, and faster healing are observed
improvements compared with standard liposuction
techniques.13
ULTRASOUND-ASSISTED LIPECTOMY
Internal and external ultrasound assisted lipectomy have
been used by many surgeons. Ideal candidates are per-
sons between the ages of 35 and 45 years with excess
adipose volumes in the lower face and cervical areas.
Ultrasound has been shown to aid in the reduction of
adipose volume, induce skin retraction, and refine de-
Downloaded by: University of Florida. Copyrighted material.
sired contours.15 Details of the technique may be found
in the referenced citations.
LIPOSHAVER
Recent advances in instrumentation have resulted
in the development of lipectomy using microde-
briders.16,17 A 2-cm incision is made posterior to the
submental crease. The skin is elevated in the subdermal
plane so that the fat remains attached to the platysma
rather than being elevated with the skin flap. The
shaver is used to remove adipose tissue superficial to
the platysma. Proposed advantages of this technique
over more traditional liposuction include less bruising,
quicker recovery, and less irregularity of the skin fol-
lowing redraping.
Figure 1 Access to the neck and jowls can be ac-
complished through a small submental incision.
150 FACIAL PLASTICS SURGERY/VOLUME 22, NUMBER 2 2006

Downloaded by: University of Florida. Copyrighted material.

Figure 2 (A, B) Preoperative views of a 49-year-old woman with excess submental and neck adipose tissue. (C, D) Postoperative
views after submental liposuction. The refined cervicomental angle improves the overall aesthetic appearance.

SUSPENSION SUTURES interlocking sutures are used to bring the platysma

Suture suspension of facial soft tissue may be used to together in the midline by anchoring the paramedian
further refine liposuction results without proceeding to a edges of the platysma to the contralateral mastoid peri-
formal facelift (Fig. 4). Following neck liposuction, osteum. Good short-term results have been documented

Figure 3 Small preauricular and postauricular incisions provide
improved access to the jowls and midface.
in patients with a poorly defined cervicomental angle,
poorly defined submandibular border, absence of mid-
facial laxity, and small to moderate amounts of jowl and
neck fat.18
Figure 4 Platysmal band correction following liposuction.
FACIAL LIPOSCULPTURE/HAACK, FRIEDMAN 151
TECHNIQUE OF AUTOLOGOUS FAT
TRANSPLANTATION
The cherubic appearance that characterizes the youth of
a baby’s face is lost with age as fat pads descend and
adipose tissue atrophies. Diffusely augmenting visible
structures such as the jawline, mouth, cheeks, and chin
can restore a youthful look.19–22 Innovations in facial
contouring have improved the surgeon’s ability to
achieve aesthetically pleasing results by augmenting
atrophied fat pads and restoring facial symmetry.
Since the early 20th century, surgeons have tried a
variety of inert substances for facial augmentation such
as gold, silver, rubber, and ivory.19 Autologous substan-
ces offered excellent biocompatibility but the results
were short-lived due to reabsorption. Prior to the advent
of liposuctioning techniques in the 1970s, blocks of fat
were transferred from donor sites such as the abdomen,
thighs, and buttocks to the desired location. A high
reabsorption rate associated with these techniques di-
minished enthusiasm for this approach to the aging face.
Downloaded by: University of Florida. Copyrighted material.
With the advent of liposuction, a large amount of
autologous fat could be harvested with minimal donor
site morbidity. Improved understanding of adipocyte
physiology demonstrated that a maximum 3-mm diam-
eter of free transplant tissue must be utilized for optimal
results.23 Modern techniques of fat transfer, fat injec-
tion, liporecycling, lipostructure, and microlipoinjection
have proven to be reliable and long-lasting.19 These
techniques have been employed for traumatic deform-
ities, hemifacial atrophy, lipodystrophy, facial rhytides,
malar augmentation, chin augmentation, postliposuction
irregularities, and many others.24 Superficial defects, fine
lines, and bound-down scars have responded less favor-
ably to fat injections.
The most popular methods of fat harvesting
include either syringe extraction or machine-assisted
extraction. Syringes of 3 to 10 mL are used with large
14-gauge needles or blunt end microcannula tips. After
insertion of the needle, gentle negative pressure and
repeated back and forth motions are used to harvest
donor fat. Machine-assisted adipose extraction uses
standard liposuction instrumentation, with a fat trap or
alternative collecting system. Advantages to the syringe
system include less traumatic harvesting due to lower
negative pressure and less manipulation of the adipose
tissue. Machine-assisted liposuction allows for large
quantities of easily harvested donor tissue.24
Once harvested, the useful fat is isolated from the
nonuseful fluids and fibrous connective tissue prior to
reinjection. Light centrifugation may be used to separate
the harvested fat lobules from fluids and fibrous con-
nective tissue. Alternatively, one may filter the fluids
from the fat through an operative sponge or with needle
aspiration in an effort to minimize potential trauma.25 It
is thought that by minimizing trauma to the fat lobules,
final graft survival is greatly improved.19 Excess fat can
152 FACIAL PLASTICS SURGERY/VOLUME 22, NUMBER 2 2006
be frozen and used for revision treatments for up to
2 years following its harvest. The fat should be clearly
marked and stored in a freezer at 208C.26
The recipient zone can be anesthetized with a
regional or local nerve block, but care should be taken
not to distort the operative field with high volumes of
local infiltrative anesthetic. Fat injection can then be
performed with 1-mL syringes. The needle or blunt end
cannula should be inserted to the desired location and fat
is injected while withdrawing the syringe. Minimal
positive pressure is placed on the syringe and multiple
passes are made to achieve a smooth natural look. Most
commonly, the fat is injected into the subcutaneous
plane with slight overcorrection. The amount of fat
injected at each location will depend on the amount of
correction or augmentation desired, as well as the ability
of the soft tissue to accommodate the infiltrated fatty
tissue. The deepest layer is first injected and subsequent
passes are aimed more superficially, taking care not to
reinsert the needle in previously created tunnels. After
injection, the operator may mold the corrected areas to
avoid minor surface irregularities. For optimal results,
patients may require multiple treatment sessions.19 In-
tradermal injection may also be conducted with a
smaller-gauge needle, but the injected fat may lack the
easy fluence of collagen and other filler compounds.25
INDICATIONS AND USES FOR
LIPOSCULPTURE IN THE HEAD
AND NECK REGION
When combined with facial liposuction, fat augmenta-
tion can help to restore appropriate facial proportions to
the aged face. Each facial subunit is carefully evaluated to
determine whether fat should be removed or added. Free
fat grafting can smooth prominent furrows and create
youthful contours in areas of facial rhytids and atrophied
soft tissue hollows.
A strong jawline is a desirable facial feature that
creates a healthy, refined appearance. Autologous fat
injections at the point of the mentum can improve chin
fullness and increase projection. Chin implantation us-
ing alloplastic substances has been the most common
method of improving the poorly defined chin. Autolo-
gous fat transplantation can augment a chin transplant or
in some it may be used to avoid the need for a synthetic
chin implant altogether. The addition of fat along the
mandibular border allows the surgeon to create a strong
posterior mandible and to create a natural fullness along
the body of the mandible. Jowls may be concealed by
adding bulk to areas anterior and posterior to the jowls
along the mandibular line. Relative facial proportions
may be restructured with this method, by creating the
appearance of a smaller chin.19
As the malar fat pad descends with aging, it often
appears to split along the orbitomalar ligament. A
double fold appears along the lower eyelid-cheek con-
tinuum.27 The result of this tissue atrophy and migration
is a tired and hollow appearance of the upper midface.
Autologous fat injection deep to the orbicularis oculi
restores a smooth contour to the lid and cheek. Aug-
mentation and improved projection of the zygomatic
ridge emphasizes the desired heart-shaped appearance of
the female face. Malar augmentation due to facial
asymmetry or trauma may also be accomplished with
fat transplantation.3
Prominent melolabial folds are one of the most
apparent signs of aging. Autologous fat transplantation
to the melolabial folds and malar fat pads softens the
visible crease, creating a more youthful appearance.
A poorly accentuated lip vermillion has long been
targeted by cosmetic surgeons. Injection of autologous
fat or filler compounds has been successfully used to
create greater red lip volume, which is characteristic of a
youthful face.19 Additionally, a deepened melomental
fold and downturned corner of the mouth may project a
Downloaded by: University of Florida. Copyrighted material.
negative and sour appearance.27 Targeted fat augmenta-
tion to the lower face including the melomental folds,
the lips, and the mental groove can soften these hard-
ened signs of aging. Additional zones of potential
augmentation include the temporal fossa, lateral eye-
brow, and the glabella.22
COMPLICATIONS
Despite the apparent simplicity of the techniques de-
scribed, complications abound in the realm of liposuc-
tion and lipocontouring. Postoperative edema, pain,
ecchymosis, hematoma, seroma, or infection may occur.
Precautionary measures such as perioperative antibiotics,
adequate hydration, and appropriate technique and pa-
tient selection will help limit such complications. In a
series of 500 cases of autologous fat injections with open
processing techniques a single deep infection was ob-
served.25 Catastrophic complications are rare but have
been reported. For example, a single case of unilateral
vision loss due to intravascular injection and ophthalmic
artery occlusion has been reported.24
Aesthetic complications associated with lipec-
tomy are related to technique and judgment.28 Contour
irregularities, depressions, and asymmetry are the most
common technical complications in liposuction and lip-
ocontouring. These deformities may be minimized with
the use of a conservative approach and careful manipu-
lation of the instruments.
Aggressive liposuction techniques can result in
facial nerve injury, with the marginal mandibular nerve
most commonly affected. In most cases, the nerve
weakness will spontaneously resolve within 6 weeks,
as it is rare to transect the nerve and the injury is
generally one of blunt trauma to the nerve. Minimal
weakness has been reported in up to 5% of liposuction

patients, but no episodes of permanent paralysis were
reported.11
CONCLUSION
Facial liposculpture has been found to be effective in
facial rejuvenation. As with any procedure, proper tech-
nique and patient selection will help to ensure excellent
results. The future of facial rejuvenation will likely
continue to incorporate liposculpture techniques as pa-
tients and surgeons seek to achieve maximal results with
minimal recovery time and morbidity.
REFERENCES
1. Chrisman B. Liposuction with facelift surgery. Dermatol
Clin 1990;8:501–522
2. Illouz YG. Body Sculpting by Lipoplasty. New York:
Churchill-Livingstone; 1989
3. Asken S. Facial liposuction and microlipoinjection. J Dermatol
Surg Oncol 1988;14:297–305
4. Chrisman B, Field L. Facelift surgery update: suction-
assisted rhytidectomy and other improvements. J Dermatol
Surg Oncol 1984;10:544–550
5. Markman B. Anatomy and physiology of adipose tissue. Clin
Plast Surg 1989;16:235–244
6. Van R, Bayliss C, Roncari D. Complete differentiation of
adipocyte precursors: a culture system for studying the
cellular nature of adipose tissue. Cell Tissue Res 1978;195:
317–329
7. Van R. The Adipocyte Precursor Cell. London: Butter-
worths; 1985
8. Gasperoni C, Salgarello M. Rationale of subdermal super-
ficial liposuction related to the anatomy of subcutaneous fat
and the superficial fascial system. Aesthetic Plast Surg 1995;
19:13–20
9. Illouz Y, Flageul G. Isolated cervicofacial liposuction in facial
rejuvenation. Perspect Plast Surg 1996;10:1
10. Mladick R. Lipoplasty: an ideal adjunctive procedure for the
face lift. Clin Plast Surg 1989;16:333–341
FACIAL LIPOSCULPTURE/HAACK, FRIEDMAN 153
11. Morrison W, Salisbury M, Beckham P, Schaeferle M 3rd,
Mladick R, Ersek RA. The minimal facelift: liposuction of
the neck and jowls. Aesthetic Plast Surg 2001;25:94–99
12. Asken S. Perils and pearls of liposuction. Dermatol Clin
1990;8:415–419
13. Klein J. Tumescent technique chronicles. Dermatol Surg 1995;
21:449–457
14. Klein J. The two standards of care for tumescent liposuction.
Dermatol Surg 1997;23:1194–1195
15. Grotting JC, Beckenstein M. Cervicofacial rejuvenation
using ultrasound assisted lipectomy. Plast Reconstr Surg
2001;107:847–855
16. Becker D, Cook T, Wang T. A 3-year multi-institutional
experience with the liposhaver. Arch Facial Plast Surg 1999;
1:171–176
17. Schaeffer BT. Endoscopic liposhaving for neck recontouring.
Arch Facial Plast Surg 2000;2:264–268
18. Giampapa VC, Bernardo BE. Neck recontouring with suture
suspension and liposuction: an alternative for the early
rhytidectomy candidate. Aesthetic Plast Surg 1995;19:217–223
19. Coleman S. Facial recontouring with lipostructure. Clin Plast
Surg 1997;24:347–367
Downloaded by: University of Florida. Copyrighted material.
20. Fournier P. Facial recontouring with fat grafting. Dermatol
Clin 1990;8:523–537
21. Coleman S. Long-term survival for fat transplants: controlled
demonstrations. Aesthetic Plast Surg 1995;19:421–425
22. Tzikas T. Lipografting: autologous fat grafting for total facial
rejuvenation. Facial Plast Surg 2004;20:135–143
23. Carpaneda CA, Ribeiro M. Percentage of graft viability
verses injected volume in adipose autotransplants. Aesthetic
Plast Surg 1994;18:17–19
24. Drake LA, Dinehart SM. Guidelines of care for soft tissue
augmentation: fat transplantation. J Am Acad Dermatol
1996;34:690–694
25. Sattler G, Sommer B. Liporecycling: a technique for facial
rejuvenation and body contouring. Dermatol Surg 2000;26:
1140–1144
26. Donofrio L. Fat rebalancing: the new ‘‘facelift.’’ Skin Therapy
Lett 2002;7:7–9
27. Carruthers J, Carruthers A. Facial sculpting and tissue
augmentation. Dermatol Surg 2005;31:1604–1612
28. Teimourian B. Complications associated with suction
lipectomy. Clin Plast Surg 1989;16:385–394