1. Review the evaluation of patient’s motivation and postoperative goals.
2. Discuss that patients counseled during preoperative period could have results that may be unpredictable and final results may not be evident until up to 6 months.
3. Summarize the examination of head and neck anatomy with particular attention paid to findings that may be amenable to more aggressive treatments in addition to liposuction (rhytidectomy, cervicoplasty, chin augmentation):

• Skin elasticity 
• Platysmal banding 
• Submental fat pad 
• Cervicomental angle - ideally 105-120˚
• Mentocervical angle – ideally 80-95˚
• Chin projection – Line from lower lip mucocutaneous junction dropped inferiorly delineates ideal chin projection
  • Males – chin should project to point or beyond it
  • Females – chin should not go further than this line
• Nasolabial fold prominence 
• Dedo Classification for cervicomental rejuvenation
  • Class I: Well-defined cervicomental angle, good platysmal tone, no fat accumulation; requires minimal correction
  • Class II:  Skin laxity without significant fat accumulation
  • Class III: Submental liposis
  • Class IV: Platysmal banding
  • Class V: Microgenia or retrognathia
  • Class VI: Low anterior hyoid
• Photodocumentation with pre- and post-operative photography with frontal, oblique, and profile views

References

1. Kridel, RWH, Conderman, CP. Liposuction of the Face and Neck: The Art of Facial Sculpture.  In: Papel ID, Frodel JL, Holt GR Larrabee WF, Nachlas NE, Park SS, Skyes JM, Toriumi DM, eds. Facial Plastic and Reconstructive Surgery. 4th ed. New York: Thieme; 2016
2. Farrior EH, Park SS. Liposuction. In Flint P, ed. Cummings Otolaryngology: Head & Neck Surgery, 5th ed. Philadelphia, PA: Mosby/Elsevier; 2010
3. Flageul G, Illouz YG. Isolated cervicofacial liposuction applied to the treatment of aging. Ann Chir Plast Esthet 1996;41:620–630
4. Mejia JD, Nahai FR, Nahai F, et al. Isolated management of the aging neck. Semin Plast Surg 2009;23:264–273 
5. Ellenbogen R, Karlin JV. Visual criteria for success in restoring the youthful neck. Plast Reconstr Surg 1980;66:826–837 
6. Kock RJ, Hanasono MM. Aesthetic facial analysis. In: Facial Plastic and Reconstructive Surgery. New York: Thieme Medical Publishers; 2002: 135–144
7. Dedo DD. “How I do it”—plastic surgery. Practical suggestions on facial plastic surgery. A preoperative classi cation of the neck for cervicofacial rhytidectomy. Laryngoscope 1980;90: 1894–1896

1. Review ultrasound

• Energy transfer results in adipocyte disruption, fragmentation, liquefaction, and allows for easier aspiration 

2. Discuss laser

• Selective photothermolysis facilitates aspiration

3. Review radiofrequency

• Adipose tissue has high tissue impedance and therefore is selectively heated

4. Describe cool sculpting

• low temperature induces apoptosis

5. Explain Deoxycholic acid 

• FDA approved injectable has shown efficacy in treatment of submental adiposis
• Bile salt and detergent that induces pore formation within the adipocyte cellular membrane with resultant cell lysis and inflammation resulting in skin tightening

References

1. Kridel, RWH, Conderman, CP. Liposuction of the Face and Neck: The Art of Facial Sculpture.  In: Papel ID, Frodel JL, Holt GR Larrabee WF, Nachlas NE, Park SS, Skyes JM, Toriumi DM, eds. Facial Plastic and Reconstructive Surgery. 4th ed. New York: Thieme; 2016
2. Chung, Jeannie H., and Edwin F. Williams. "Facial and Cervical Lipectomy." Master Techniques in Facial Rejuvenation (2nd Edition). 2018. 305-320
3. Cook WR. Utilizing external ultrasonic energy to improve the results of tumescent liposculpture. Dermatol Surg 1997;23: 1207–1211
4. Igra H, Satur NM. Tumescent liposuction versus internal ultra- sonic-assisted tumescent liposuction: a side-to-side comparison. Dermatol Surg 1997;23:1213–1218
5. Lawrence N, Coleman WP. The biologic basis of ultrasonic liposuction. Dermatol Surg 1997;23:1197–1200
6. Goldman A. Submental Nd:Yag laser-assisted liposuction. Lasers Surg Med 2006;38:181–184
7. Sasaki GH, Tevez A. Laser-assisted liposuction for facial and body contouring and tissue tightening: a 2-year experience with 75 consecutive patients. Semin Cutan Med Surg 2009;28: 226–235
8. Blugerman G, Schavelzon D, Paul MD. A safety and feasibility study of a novel radiofrequency-assisted liposuction technique. Plast Reconstr Surg 2010;125:998–1006
9. Alster TS, Tanzi E. Improvement of neck and cheek laxity with a nonablative radiofrequency device: a lifting experience. Dermatol Surg 2004;30:503–507
10. Rzany B, Griffiths T, Walker P, Lippert S, McDiarmid J, Havlickova B. Reduction of unwanted submental fat with ATX-101 (deoxy- cholic acid), an adipocytolytic injectable treatment: results from a phase III, randomized, placebo-controlled study. Br JDermatol 2014;170(2):445-453

1. A 62-year-old female presents for evaluation of facial aging. On physical examination she has moderate skin elasticity, platysmal banding, and significant rhytids. She does not exhibit significant submental liposis although she does mention that she does not like her jowls.  She is interested in pursuing cervicofacial liposuction and asks if this may be performed as the primary treatment to address her concerns.

• Patients must be appropriately counseled regarding realistic expectations following procedural intervention
• Patients with significant facial atrophy, skin laxity, and ptosis of the midfacial soft tissue envelope may benefit from multimodal therapy utilizing formal rhytidectomy with adjunctive liposuction

2. A 37-year-old male presents with concerns that his well-defined jawline has become more blunted with age.  He states that he used to have a well-define muscular neck with a prominent Adam’s apple and strong masculine features that have decreased with time.  Despite a rigorous diet and exercise regimen, with significant weight loss, his jaw line remains unchanged. He has evidence of submental liposis without platysmal banding or microgenia

• Counsel the patient regarding lifestyle-modification resistant liposis primarily within the submentum and jaw-line.  Given his relatively youthful features he is likely a candidate for primary liposuction
• A standard infralobular and submental approach toward lipcontouring will address both the jowls and submental adipose tissue accumulation

References

Case 1

1. Chung, Jeannie H., and Edwin F. Williams. "Facial and Cervical Lipectomy." Master Techniques in Facial Rejuvenation (Second Edition). 2018. 305-320
2. Cuzalina LA, Koehler J. Submentoplasty and facial liposuction. Oral and maxillofacial surgery clinics of North America. 2005 Feb;17(1):85-98

Case 2

1. Kridel, RWH, Conderman, CP. Liposuction of the Face and Neck: The Art of Facial Sculpture.  In: Papel ID, Frodel JL, Holt GR Larrabee WF, Nachlas NE, Park SS, Skyes JM, Toriumi DM, eds. Facial Plastic and Reconstructive Surgery. 4th ed. New York: Thieme; 2016
2. Chung, Jeannie H., and Edwin F. Williams. "Facial and Cervical Lipectomy." Master Techniques in Facial Rejuvenation (2nd Edition). 2018. 305-320