INTRODUCTION
Defined Jawline
An extra fat pad under the chin is very common. It is usually an inherited condition and unfairly makes people look overweight by obscuring the jawline. A well-defined jawline is attractive. Just look at any model or actor (there’s a reason Alfred Hitchcock was behind the camera and Cary Grant was in front). It is common for men to use facial hair such as goatees to give definition to their jawline. You can observe this trend among major league baseball players. In fact, men with well-defined jawlines tend not to camouflage their jawline with facial hair, because there is no need. The cheek should not blend into the neck. The area under the chin is one of the few places on the body where flatness is preferred! The angle between the jawline and the neck, when viewed in profile, should be about 110 degrees, or a right angle if the sternomastoid muscle is used as a reference (See photo).
This procedure may be done on its own or in combination with a chin implant. The procedure is straightforward. It involves an incision just under the chin. There is often a skin crease or an old scar at this location anyway.
Patients often come to see me interested in liposuction of the body or another cosmetic surgical procedure. If they have an extra fat pad under the chin, I don’t mind pointing this out. They are invariably aware of it already. They may have first noticed this unwanted fat collection in a photograph that caught their profile, taken at an event such as a wedding. They often decide to have this fat pad treated at the same time as their other surgery. Frequently, they tell me after surgery that this was their favorite, because the result is so visible.
What Is “Submental Liposuction”?
Liposuction under the chin is known as submental liposuction. Often some additional fat is removed directly by cutting it out (“excision”) at the same time. Technically, when fat is cut out as opposed to just suctioned out, the procedure is called a submental lipectomy, although the terms are close to synonymous. Most plastic surgeons do both liposuction and direct fat excision to achieve the best profile.
Submental Liposuction in Combination With a Facelift
A submental lipectomy does not tighten the skin of the neck and does not treat jowls. For patients under 40, the degree of skin laxity is usually minimal and a submental lipectomy suffices. However, for patients over 40, there is typically some skin laxity. The decision is whether to have a submental lipectomy alone or with a facelift. The submental lipectomy improves the profile, even when there is excessive skin laxity, but the skin tone does not improve. Jowls persist. If the jowls or loose skin of the neck are priorities, there is no substitute for a facelift, which is commonly done with a submental lipectomy.
Nonsurgical Methods for Fat Reduction
Coolsculpting has been used to freeze the fat under the chin. Kybella is a noxious chemical that dissolves fat. Both of these methods create swelling and often require repeated treatments. The results from surgical treatment are superior and the cost is usually not much more (these nonsurgical treatments can be expensive). Many of my patients have come for surgery after being dissatisfied with these methods performed in other offices. Operators who use these methods are not always surgeons and do not have that option to offer their patients. I remember attending a seminar on Kybella in which the presenter did not show a single set of before and after photos – always a red flag.
PATIENT PHOTOS
M.C., Age 22
Procedure: Submental Liposuction, ultrasonic liposuction of abdomen, flanks, inner thighs, arms and axillae (armpits and bra fat).
Before, 1 year after
C.B., Age 23
Procedure: Submental lipectomy, breast augmentation, ultrasonic liposuction of abdomen, flanks and thighs
Before, 3 months after (with makeup)
CL 27.
Submental lipectomy, excision of skin lesions of face and neck.
2.5 months.
S.G., Age 37
Procedure: Submental liposuction, rhinoplasty, scar revision of upper lip, and laser treatment of facial spider veins.
Before, 3 months after
LB 43.
Procedure: Submental lipectomy.
3 months.
J.S., Age 45
Procedure: Submental lipectomy
3 months
DB 53.
Procedure: Upper and lower blepharoplasties, submental lipectomy, fat transfer to face, chin augmentation, buccal fat pad resection.
6 months.
The procedure is usually done under intravenous sedation. It may be done on its own or at the same time as liposuction of other areas of the body or with a facelift.
The Incision
An incision is made at the level of the crease under the chin. This way, the incision is hidden on the underside of the chin, not further down onto the neck where it might be visible, which is a more traditional placement, but a more conspicuous one.
The incision is 2 or 3 centimeters long, about an inch. If liposuction alone is done (which is unusual), the incision may be shorter (under a centimeter), but such a short incision does not allow direct excision of submuscular fat or a muscle repair, which are important to achieve maximum flattening of the submental contour. If the incision is well-positioned, it is usually well hidden. The additional centimeter or 2 in length is inconsequential. Any existing scar at this site, from childhood or adolescent trauma, may be revised simultaneously.
Muscle Repair
When doing submental liposuction, I almost always perform a “corset platysmaplasty,” which simultaneously tightens the platysma muscle under the chin, improving the result. This muscle repair also helps avoid the “turkey waddle” deformity that can occur in later years, so it has preventive value. I usually remove some fat under the muscle too (See Illustration).
Redo
It is not unusual for me to treat patients who have had previous liposuction under the chin. Usually they say there was an improvement after their original surgery, but not as much as they had hoped for. With additional fat removal under the muscle and tightening the muscle sling by sewing the edges together like a zipper (“plication”), it is usually possible to satisfy their expectations. On occasion, I have re-treated my own patients at future dates to keep their jawline clean and well-defined.
Laser Assistance—Questionable Benefit
Some operators have used a laser system (example, Smartlipo) in conjunction with liposuction, claiming less bruising and a shorter recovery time because the laser energy seals blood vessels. However, this system is applicable only to small areas of fatty tissue. The cannula (long metal tube with a hole at the end) is too narrow to make it practical for body liposuction.
Whether such systems offer any improvement in skin tightness is questionable. (The same is true for radiofrequency systems that are supposed to cause contraction by heating the deeper layers of the skin.) These systems are costly to purchase. Laser liposuction adds a price increment because a nonreusable tip is needed. Further, laser use in liposuction is not selective for fat cells. Studies have failed to show a definite advantage.
There is another reason this system does not provide a major advantage. The muscle repair is typically not done if a laser system is used, because the advantage of such a laser is to minimize the swelling, bruising and downtime. If a muscle repair is done, along with direct excision of submuscular fat, there is no longer an advantage in using such a laser system because the muscle repair causes some degree of swelling and bruising anyway, so the advantage of the laser in reducing recovery time, if there is one, is a moot point.
Open Approach—Better Results
Fat under the muscle is removed only by direct excision, which simply means cutting it out as the operator looks at it through the incision, as opposed to liposuction, which is done without actually visualizing the fat. Surgeons call direct excision the open approach.
There is a debate in plastic surgery between those surgeons who advocate the open approach to the neck (I’m one of them) and those who rarely “open a neck.” Surgeons using the closed approach rely on liposuction alone. Liposuction helps, but the jawline is unlikely to be sufficiently flattened without the muscle repair. The improved neck contour after the muscle repair is readily visible in surgery (much like the flattened tummy during abdominoplasty), which is why I almost always do it.
Fortunately, the recovery time is not long anyway, measured in days, so that the disadvantage of a few extra days of bruising is more than compensated by the improved result. My philosophy is to try to get the best result without compromise, and then make the recovery as tolerable as possible.
It does not necessarily follow that a lesser procedure has a shorter recovery time. Unfortunately, there is a tendency for inexperienced operators or nonsurgeons doing liposuction to be overaggressive, and cause more bruising and swelling trying to do too much with a single modality in an effort to match the result obtained by an experienced surgeon doing an open neck procedure in conjunction with liposuction.
Immediately Following Surgery
When patients wake up after surgery, they are wearing a chin strap that wraps snugly around the chin and neck. It has Velcro straps that can be loosened if it feels too tight. This strap is removed in the office the day after surgery. It helps to reduce swelling after surgery. If patients are planning to be at home anyway (and most are), they can wear the chin garment to help the swelling go down more quickly, but this is optional. They can shower and bathe the day after surgery, after the garment is removed in the office.
Bruising
Bruising is the giveaway after a submental lipectomy, and it is not where you might predict—not on the underside of the chin, but farther down the neck, even extending onto the chest in some patients. Bruising is caused by blood under the skin that is left over from surgery. It tracks down with gravity, extending to areas that were not treated at all during surgery. Fortunately, bruising of the lower neck can be hidden with clothing. Usually younger patients bruise less than older patients.
Numbness
There is always an area of numbness under the chin, caused by surgical trauma to the fine sensory nerve branches to the skin. It takes a few months for these nerve branches to recover. This temporary numbness does not pose a problem for patients; they just need to know to expect it. Men need to be careful shaving until the feeling fully returns.
Sutures
There is usually one continuous running suture that is removed 3 to 5 days after surgery. Sometimes additional small incisions are used, placed in the earlobe creases. I use these additional small incisions for liposuction of the cheeks in patients with unusually chubby cheeks, sometimes in combination with resection of the buccal fat pads.
Lip Weakness
Occasionally, there may be some weakness of the lower lip on one side, caused by trauma to a motor nerve (the “marginal mandibular” branch of the facial nerve) that supplies the muscle that pulls down on the corner of the mouth. This one-sided weakness can cause a conspicuous asymmetry when the patient smiles, because the lower lip on the affected side does not move down to show the teeth on this side. Patients may complain, “I look like I had a stroke!” Fortunately, this function returns as the nerve recovers. Sometimes patients may experience difficulty articulating after surgery due to swelling and muscle weakness. This problem is typically short-lived, clearing within a week or two.
Swelling
Swelling is expected. Typically, even with swelling present on the day after surgery, the fullness under the chin is less than it was before surgery. The improvement is evident when the chin strap comes off the day after surgery. Patients may remark how hard the area under the chin feels right after surgery. Fortunately, this firmness (induration) is usually more noticeable to the patient than to other people, and it gradually softens as the swelling goes down. After a few months, the area under the chin feels just as soft as it did before surgery. I usually wait 3 months before taking postoperative photographs because there is a noticeable improvement in swelling between 1 month and 3 months. Fortunately, this firmness is not evident to others. Occasionally, if the firmness does not seem to be softening, I inject a small amount of a steroid solution to help it resolve more quickly.
Scarring
The scar starts out raised and feels thick. There may be some bumpiness (irregularity). With time, the scar gradually softens and flattens (“matures”), like scars everywhere.
Undertreatment
After submental liposuction alone, patients are likely to notice an improvement in the neckline, but perhaps not as much as they had hoped for. Fortunately, such patients may be re-treated with direct excision of any excess fat under the muscle, and a platysmaplasty to maximize jawline definition.
Overtreatment
Overzealous liposuction by an inexperienced operator trying to do too much with liposuction alone can result in unsightly skin dimpling and irregularity as the skin attaches to the underlying muscle. Overresection of submuscular fat can cause a concavity of the submental area (the “cobra” deformity). Fortunately, these problems can be treated with fat injection, but are obviously best avoided.
Seroma
Any time an area of skin is undermined by surgical dissection, a potential space is created where fluid can accumulate. Surgeons call this a “dead space” (an unnecessarily bleak description). Fluid backs up in to this space because the lymphatic circulation has been traumatized by surgery. Lymphatics are tiny, invisible veins that normally drain fluid out of the tissues, emptying it into the venous circulation. These little vessels regenerate quickly, but for a short time, there may be a backup of fluid. A drain may be used to allow this fluid to come out, so that it does not collect under the skin and form a seroma. For some operations that involve a large area of skin undermining, such as an abdominoplasty, surgeons almost always use a drain. However, the area under the chin is much smaller, so that a drain is usually not required. If a seroma does occur, I treat drain it by simply inserting a needle in the office and drawing off the fluid. Fortunately, the skin is still numb so it doesn’t hurt much. I may have to repeat these aspirations several times at subsequent office visits. Eventually the lymphatics take over and the fluid stops accumulating
Hematoma
This is an unusual complication after a submental lipectomy, signaled by increased swelling of the neck shortly after surgery, usually within 24 hours. If there is increased swelling of the neck after surgery, patients need to call the office right away and come in to be assessed. If there is a hematoma, they will probably require a return trip to the operating room to find out what is bleeding and to stop it. If this complication is recognized and treated promptly, the result should not be compromised, although there will be more than the usual amount of bruising that will cause quite a colorful display on the neck.
Persistent Swelling
It can take months for the swelling to fully subside and for the induration (hard feeling) under the chin to soften. Occasionally, if there is a persistent area of swelling and firmness, I may inject a small amount of a steroid solution to soften the tissues more quickly.
Asymmetry
For experienced plastic surgeons, noticeable asymmetry is rare. A mild degree of asymmetry in fat removal may be treated with a touch-up liposuction under local anesthesia.
Scarring
Sometimes the scar heals with a raised area of thickening that makes it more noticeable. A thickened (“hypertrophic”) scar may be revised under local anesthesia if it is conspicuous.
Nerve Injury
Sensory nerves are traumatized by the surgery. This happens to everyone and is expected, so numbness may be considered a side effect rather than a complication. Sometimes the motor nerve to the muscle of the lower lip is traumatized by liposuction, causing asymmetry of the lower lip and may take a few months to recover.
Infection
Infection is a risk but is unusual because of the excellent blood supply of the head and neck tissues.
Getting Back to Normal
- Leave the chin strap on until your visit to the office on the day after surgery. The Velcro straps may be adjusted if it feels too tight. It is better for the garment to be too loose than too tight. If it is uncomfortable, just take it off.
- If you develop increasing swelling of the neck, call the office right away. Increased swelling may indicate a hematoma and needs to be checked.
- After your visit to the office the day after surgery, you can shower and bathe. The incision can get wet. If there is a Steri-Strip in place over the chin incision, leave it on. This adhesive tape is removed when it is time for the suture to come out, 3 to 5 days after surgery.
- Do not pull on the ends of the blue suture. Men need to avoid shaving in the area of the incision and I instruct them not to trim the suture ends because this makes it difficult to take out the suture. Remember, the skin is still numb and you need to be careful shaving. Most men do not bother shaving at all until after the sutures are removed, 3 to 5 days after surgery.
- It is best to wait about a week before exercising. If you work out too soon after surgery, swelling will increase.
Q: Will this fat pad go away if I lose weight?
A: The fat pad gets smaller, just as fat cells everywhere get smaller as you lose weight. However, there will still be an excess of fat cells, even at lower weights, so the problem is unlikely to go away completely. It is, after all, a genetically determined concentration of fat cells that is causing the problem. Most patients are aware that they had extra fat in this location even when they were much younger or in excellent physical condition. This fat pad makes them look pudgy, not lean and fit. Fortunately, this problem is well-treated with a submental lipectomy.
Q: Will the fat come back?
A: The fat cells that are removed are gone forever. The remaining fat cells will swell and shrink in response to your overall weight gain or loss, but whatever your weight, the contour under your chin will always be better than it would have been without the submental lipectomy. The surgery provides a permanent improvement in your profile.
Q: How long is the scar?
A: The scar is typically 2 to 3 centimeters long (about an inch). It is possible to use a shorter scar if liposuction is done without direct excision of fat tissue and tightening of the platysma muscle sling, but these maneuvers are so helpful that they justify a slightly longer incision. If the incision is correctly placed in the crease under the chin and not farther down where it might be seen on the neck, the scar is usually inconspicuous.
Q: Is it painful?
A: Usually this procedure is not painful, although there is a tight sensation in the neck afterward, as you might expect.
Q: How long do I have to wear the chin strap?
A: Just overnight. But many patients continue to wear it at home for several days to provide some gentle compression and help the swelling go down faster.
Q: Will this procedure also tighten the skin, or will it make the skin tone worse?
A: A submental lipectomy removes fat and tightens the muscle sling under the chin. It does not remove extra skin. For older patients, who have loose skin that needs to be addressed, a facelift is recommended (a facelift tightens the skin of the neck). A facelift typically includes a submental lipectomy. Sometimes patients may not be ready for a facelift and wish to do something less. Older patients may still have a submental lipectomy to improve their profile, recognizing that they can return in a few years to have the skin laxity treated with a facelift. Fortunately, a submental lipectomy does not make the skin looser, although there is likely to be negligible skin tightening, especially in older patients.
Q: Is there a laser that could be used to minimize downtime?
A: Lasers have been adapted for use with liposuction (SmartLipo). The concept is that the laser energy helps seal blood vessels and possibly provides some tightening effect. If there is less bruising, this would be expected to minimize the time off work for patients who don’t want to return to work with obvious bruising. However, it is best in almost all cases to tighten the muscle simultaneously and even remove a small amount of submuscular fat to produce a more defined neckline. Therefore, there is no real benefit in using the laser if there is going to be some postsurgical bruising from this part of the procedure. The duration of bruising is only a matter of days anyway, so bruising is not a major issue. Patients are willing to tolerate a little more bruising and swelling if the result is better.
Q: Do you do anything to the muscle?
A: Yes, I sew the edges of the muscle together in the midline of the neck, like a zipper (called plication). These muscle borders tend to be genetically separate (“decussation” of fibers) and can even let fat hang between the borders in later years causing an unsightly turkey waddle (any similarity to turkey anatomy being unattractive in humans). The benefit of the muscle repair is threefold—removal of some submuscular fat, tightening of the neckline (the effect is transmitted to the overlying skin), and a preventative measure to avoid the turkey waddle deformity from developing later on.
Q: Do you cut the muscle?
A: No. In the past, plastic surgeons often cut the platysma muscle horizontally in an effort to treat vertical bands in the neck and to improve the angle between the jaw and the neck (“cervicomental angle”). Although this maneuver was effective, there was a higher risk of bleeding during surgery and this method could sometimes produce a “popsicle neck” appearance (the head appearing like a bobblehead). It turns out that sewing the muscle edges together—the corset platysmaplasty—treats the vertical muscle folds with less risk of bleeding and without creating an unnatural look.
Q: How long do I need to take off work?
A: Swelling is not usually the limiting factor, because even with maximum swelling the day after surgery, there is usually less fullness than there was before surgery. The duration of bruising tends to set the recovery time. Bruising typically accumulates in the lower neck because of gravity, not right under the chin. It usually takes about 10 days for this bruising to fade, but it can take much longer in older patients. Fortunately, this bruising may be hidden by clothing.
Q: Will people be able to tell I had surgery?
A: The incision is typically well hidden under the chin where there is often a crease anyway. At first, the scar is a little bumpy. The scar gradually flattens with time, the redness fades, and the irregularities smooth out. After surgery, other people invariably think patients have lost weight, not that they had liposuction.