Cervicofacial liposculpture has made a considerable contribution to neck and facial plastic surgery. The procedure allows for a significant rejuvenation of the face, particularly in those patients who have considerable neck and lower cheek ptosis with cutaneous deterioration. A good surgical indication not only calls for perfect surgical expertise, but also for good aesthetic sense. Difficult cases are represented in patients who have skin alterations with major sagging, and often dehydration. This usually concerns patients over 60 years of age, but can sometimes affect younger individuals. The greatest difficulty lies in patients who have an almost non-existent adipose panicle (i.e. fat under the skin), for whom a solution must be found before moving to cervicofacial lifting. Cervicofacial liposculpture allows — first through non-aspiration tunnelisation, then an adapted aspiration — the restoration of the natural oval of the face. This lifting effect is obtained through retractile cicatricial fibrosis.
Subcutaneous fat plays an essential morphological part in facial aesthetics. Just like a veil, it softens, shapes and erases subjacent osteomuscular angles by softening and rounding their sharp aspect. In the young adult, the face is oval, with the triangle of beauty resting on the features of the cheekbones and chin. Therefore, beauty in a female face does not simply rest on its tight, smooth and wrinkle‑free aspect, but also on harmonious curves and roundness.
In cases of fat excess, it will prevail in the lower area and as a result of gravity, the face will look heavier, fuller, the mandibular contrast is erased and the cervical–chin junction will lack definition. On the other hand, in cases of fat atrophy, the lower third of the face will be affected, with an emaciated, flat, and angular appearance, and a lack of grace owing to the absence of contrast and curves.
Anatomy of ageing
As with the rest of the body, two kinds of fat can be seen on the face. A common or metabolic fat can be seen on the cheeks and lateral sides of the neck, causing permanent metabolic exchanges; and a genetic or reserve fat, which is very stable and present under the chin and jaw, as well as the furrows from the side of the nose to the corners of the mouth.
The fat tissue spreads over a number of facial areas:
- Subcutaneous plane (subcutaneous fat)
- Sub-platysmal fat
- Zygomatic and sub-aponeurosis (Bichat’s lump).
The skin and subcutaneous fat are ectodermic in origin and together form the superficial adipo-cutaneous system (SACS)1. At the periauricular area, the subcutaneous layer thickens farther from the ear and constitutes the framework of the lower half of the face. Significant fat accumulations concern the areas under the chin and jaw.
Signs of youth and age
On a motionless face, the signs of youth are displayed in the absence of thickened contours on which skin drapes itself without folds or excess, a pure cervical and maxillary definition; no furrows from the sides of the nose to the corners of the mouth; and no sagging. Even with the effects of neck inflection and gravity, the youthful face will show no sagging where the cheeks reach the lower cheeks; the furrows from the sides of the nose do not meet the bitterness fold; and there is no cervical contour sagging.
With regard to the neck, it is impossible to lengthen a neck that is too short, but aesthetic surgery is not totally powerless as it is possible to work on the cervical angle and give the illusion of a slighter neck. Therefore, transforming a sagging cervical chin angle into a right angle allows a thinning of the neck volume, giving an illusion of greater height/length. To do so, the surgeon carries out either a simple lipoaspiration, or lipoaspiration combined with a neck lift. Such an operation has a spectacular effect on making the face more youthful and beautiful.
If it is easy to erase wrinkles at the upper third of the neck, it is much more difficult to smooth out the skin at the middle and lower thirds. As for peelings or possible facial laser treatments, they are rarely carried out on the neck. Today, gentle peelings using fruit acids, Krulig’s dry peeling, or botulinum injections are the only treatments likely to give some improvement. At this level, however, a small roundness can be an asset.
If the face deteriorates, sags or becomes limp, it will lose its tension, structure, and its youth and radiance. Too much weight denatures it and too much age destroys it, losing the oval shape of the face. If a face is naturally square or triangular, there is no point in trying to make it oval; it will only be worked on if there is an obvious disharmony, which usually occurs at around 50 years of age, when the lower part of the face becomes heavier. The lower cheeks are enhanced and cheekbones tend to become flatter, lose their shape and sag. In some much rarer cases, when the oval is destroyed by fleshy cheeks, the surgeon can carry out a mini liposculpture that removes surplus fat and restores a more harmonious facial shape.
The cervicofacial area is divided into three planes:
- Outside, the SACS
- In contact with SACS, the superficial muscular aponeurotic system (SMAS)
- On the ventral side of the SMAS, the second muscular layer and the vascular–nerve structures.
The anatomical plane concerning the liposculpture technique of the cervicofacial area is the SACS. Here the SACS, and the SMAS directly in contact with the SACS, are described, as well as the risk areas.
The superficial adipo-cutaneous system
The SACS is an anatomical plane that includes the skin and the subjacent adipose tissue, and which covers the cervicofacial area. Trepsat3 observes that the layer of fat thickens as it travels further from the ear towards the malar and the cheek. It can therefore be easily understood how much one can gain when carrying out a degressive tunnelisation of this area, proceeding from the thickest adipose tissue to the thinnest. Trepsat2 thus observes that in the upper part of the nasogenian grooves, the fat thickens at the level of the bulge, where it is concentrated, ‘sometimes tubulised and organised’ when this bulge is large and old.
Trespat also notes that when there is a sub-fat separation (i.e. separation of the deep SACS plane and of the SMAS), this resulting created space is ‘extremely little haemorrhage prone, since only very little perforating can be caused’.
The superficial muscular aponeurotic system
Immediately in contact with the deep plane of the SACS, the SMAS is an anatomicosurgical structure strictly derived from the primitive platysma and depending on the fascia corporalis superficialis. It presents no osseous insertion and is a continuous subcutaneous fibromuscular leaf. The muscular part composing the SMAS is made up of the platysma muscle and the risorius muscle. The fascia corporalis superficialis lengthens the muscular structure towards the zygomatic arch. The SMAS does not spread as far as the nasogenian grooves and the upper lip.
[pull_quote align=”left” ]The SACS is an anatomical plane that includes the skin and the subjacent adipose tissue, and which covers the cervicofacial area.[/pull_quote] Arterial vascularisation of the skin is ensured by the facial artery and its branches that form a vascular network under the platysma and the parotido-masseterin SMAS. The facial artery penetrates deeply within the area underneath the maxilla and spreads over the gland, thus following a first curve with inferior concavity. It then inflects and embraces the lower edge of the mandible near the anterior edge of the masseter (chin pulse) following a second curve (under the maxilla) with superior concavity. The chin pulse is an important anatomical mark as the superior mandibular branch of the facial nerve crosses the facial artery (risk area).
The facial artery then returns back up the face where it makes its way between the superficial and deep planes of the facial hypodermic muscles. Its path is sinuous; it goes past and outside the corners of the lips (labial corner pulse) then straightens along the nasogenian groove, where it takes the name of angular artery before anastomosing with the nasal artery at the inside of the eye, and connecting with the ophthalmic nerve. The transverse facial artery, parallel to the lower edge of the zygomatic arch, anastomoses to the angular artery after having distributed a few perforations for the SMAS, the orbicularis, and the skin.
The vascularisation of the skin and fat is ensured at two levels: at the main level with perforations going through the SMAS; and through direct arteries for the skin and fat.
Continuity zone between the superficial and deep malar fat tissue
A tunnelisation that does not run strictly parallel to the cutaneous plane would damage the subjacent vascular and nerve elements.
Type three decussation of the platysma muscle presents the same danger
The retroplatysmal fat is a lymphatic draining area with the under-chin and under-maxilla lymphatic network. Therefore, there is a risk of lymphorrhea.
The posterior auricular branch of the facial nerve
This can be damaged as a result of retro-auricular tunnelisation, provoking an occipital muscle paralysis and a forward sagging of the scalp, thus pulled by the forehead muscles.
The auricular branch of superficial cervical plexus
This crosses the back edge of the sternocleidomastoid muscle, goes along the SMAS and becomes superficial in the under-auricular area. Damage of the trunk provokes a definitive anaesthesia of the ear lobule.
The facial vein crosses the inferoexternal margin of the under-maxillary gland
It rarely doubles up with the superficial cervical aponeurosis, where it can be damaged.
The post-parotid branches of the facial nerve
These branches travel between the masseter and the SMAS, where the parotid exists in a cellular fascia. There are many anastomoses that allow reserve supplies should one of these branches become cut. Only the extreme branches (mandibular and temporal) are particularly vulnerable. The upper branch of the mandibular precociously crosses the lower edge of the mandible, and superficially crosses the facial artery.