According to the American Society of Plastic Surgeons (ASPS) 2013 Plastic Surgery Statistics Report, liposuction is one of the top 5 cosmetic surgery procedures performed. Demand for body contouring procedures is on the rise, most significantly due to the advent and popularity of noninvasive devices demonstrating success in fat reduction and skin tightening. Even still, surgical removal by liposuction remains the “gold standard” for reducing and/or shaping localized or widespread areas of fat. Liposuction also allows for harvesting and transfer of fat for other aesthetic procedures, and in some cases, can provide a significant improvement in skin laxity and cellulite, when performed by a meticulous and skilled aesthetic surgeon. While more common complications from skin surgery such as infection, dehiscence and scarring, are uncommon from surgical body contouring procedures, lack of experience and poor technique play the largest role in the development of asymmetries and irregularities that are frequently reported as the reason for unsatisfactory results from liposuction surgery.
In a recent realself.com post, a patient experienced neck banding shortly after a neck liposuction procedure. She wanted to know if this was a result of the procedure itself and what could be done for improvement. I suggested this patient seek out immediate evaluation. Here’s why:
Neck Liposuction Techniques
With properly performed tumescent liposuction, adhesions, scarring or irregularities should not be seen. Rather, improvements in neck and jawline contour, skin tightening and softening of platysmal bands should be noted relatively quickly after the procedure. Tumescent infiltration is easily carried out in the subcutaneous space with blunt multihole cannulas through small (1 mm to 2 mm) entrance sites in the submental location and posterior to the angle of the mandible. These incision sites are rarely seen months after the procedure, as they heal very inconspicuously even without post-procedure sutures. Several concealed entrance sites allow for multi-directional access to the submental and prejowl sulci fat pads, enabling the surgeon to contour and define the jawline. As a consequence of the back and forth motion from the aspiration cannula, fat is sculpted and the skin is lifted and then redraped along the jaw to its new shape. There is constant debate as to whether energy-based devices such as laser, ultrasound or power-assisted, help improve skin laxity. In the appropriate candidate who has soft, localized submental and jowl fat without significant skin laxity or platysmal banding, neck skin lifting can occur and does so rapidly after the procedure with continued improvement for months afterwards.
Neck tightness, adhesions, scarring and/or irregularities are extremely uncommon when performed by a well-trained surgeon with astute anatomical knowledge. If the procedure is performed too aggressively by interfering with the platysma or scraping the dermis with the aspiration cannula or energy-based device, complications can occur. Patients can experience erythema ab igne-like reticular mottling from damage to the superficial vascular system, scarring from improper redraping of the skin or exuberant collagenesis, and irregularities from oversuctioning or overheating of the subcutaneous space.
Treatment Options for This Complication
Improperly performed liposuction is devastating and extremely difficult to treat. It is best to wait three to six months before returning to a surgical intervention to ensure the entire healing process has finished and there is no longer inflammation, which may make a revision surgery more complicated. Initial interventions that may give some improvement include lymphatic massage, ultrasound or radiofrequency treatments to break apart scar tissue and decrease inflammation more quickly. Diluted corticosteroid injections with or without 5-FU every two to four weeks can help synergistically improve scarring and adhesions. Topical creams have not been shown to be effective for internal scarring, in contrast to treating keloids or hypertrophic scarring with topical imiquimod, retinoids, silicone, onion extract or vitamin E oil, which may show some benefit. In the author’s opinion, botulinum toxin should be performed 7 to 14 days prior to all liposuction procedures as this helps to release the platysma and improve redraping after the surgical procedure. In cases where scarring does not improve despite interventions, it may be necessary to revisit a surgical intervention to release adhesions with a V-type (Toledo) dissector so that the skin is free to redrape. Irregularities, often a consequence of over aspiration, too superficial removal or exuberant energy placement, may require future fat transfer or other soft tissue fillers (nonparticulate) for improvement in contours and shadows. Often, radiofrequency or ultrasound treatments can help with improvement.
Why Did This Complication Occur?
Unsatisfactory aesthetic outcomes can occur from poorly performed body contouring procedures such as neck liposuction. It is essential that training programs exist to teach board-certified aesthetic surgeons proper techniques and use of up-to-date technologies. Patients need to be made aware of risks such as irregularity, scarring, skin color change and lack of improvement in skin laxity prior to any treatment. Also there should be formal documentation that they understand these risks. My consent form fully documents these risks and other serious complications such as hematoma formation, infection, skin ulceration and nerve damage for both patient care completeness as well as medicolegal protection. Pre- and post-treatment photographs should be performed from all angles including frontal, oblique and side views. For more completeness, 3-D photography or dynamic movement (4-D) photography and/or video is even more substantial and has been extremely beneficial in high-definition body contouring (ex abdominal sculpting, gynecomastia surgery, arm defining) cases where small improvements can give sizable changes in contour and shadowing. It is also beneficial in those patients with lipedema who require substantial volume reduction and see a dramatic improvement in functional movement and swelling.
The most important take-home message for this realself.com post is the need to educate your patients of the potential complications that can occur post-liposuction surgery. Besides meticulous surgical technique, post-procedural compression is essential to reduce edema and bruising and to help skin redraping and tightening. Close follow up is critical to ensure that excessive bruising and swelling, pain, lumpiness and/or unevenness is immediately addressed and treated should they occur. Standard surgical preparation such as avoidance of blood thinners, including medications/supplements that thin the blood, and antibiotics prophylaxis should be followed. Overall, liposuction procedures can provide very satisfying results if the proper techniques are followed and impending complications are treated appropriately.
Jason Emer, M.D.