Endoscopic Liposhaving for Neck Recontouring

THE GOALS for cosmetic neck surgery are to achieve a youthful neckline by establishing a well-defined mandibular line and a sculptured mento-hyoid angle. Neck recontouring in cosmetic surgery involves management of the subcutaneous fat, platysma muscle, and cervical skin. In the early 1980s, liposuction was introduced in the United States, and it became the method of choice for lipectomy in the neck. Over the years, liposuction evolved with new developments in equipment and techniques, including cannulas, ^Article method of aspiration, ^Article position of incisions, ^Article infiltration technique, ^Article use of external ultrasound, ^Article and compression garments. Sculpturing of the neck has been aided by internal suspension slings ^Article and sutures. ^Article Cervical liposuction can be performed alone or in conjunction with a face-lift. ^{Article - Article} More recently, liposhaving has been advocated for facial plastic surgery. ^{Article - Article}

Liposuction involves passing into the subcutaneous plane a cannula attached to a high-pressure vacuum of 1 atmosphere (760 mm Hg). The quick back and forth motion of the cannula creates a tearing effect while the suction removes the fat. Palpation and direct external visualization are used for fat removal in this closed procedure. Irregularities of the skin and fat are infrequent but familiar complications of liposuction.

The modifications described in this report include use of an endoscope to optimize visualization and a soft tissue shaver to remove the fat. The shaver is an instrument for contouring and sculpturing soft tissue. It cleanly and precisely cuts the fat with minimal effort. Becker et al ^{Article - Article} concluded in their reports that "liposhaving offers a precise alternative to conventional liposuction." ^Article (p171)

Liposhaving requires regular wall suction of 200 mm Hg and direct visualization. The fat is evenly and cleanly cut with minimal trauma, resulting in less bruising and quicker recovery than with liposuction. Becker and colleagues ^{Article - Article} initially used a 2-cm submental incision. This leaves only a very narrow optical cavity when the blades are in position. This author developed the technique of passing an endoscope into the subcutaneous plane for optimal visualization, resulting in a clearer and magnified field that can illuminate the limits of dissection and any fatty irregularities. The undersurface of the skin flap and surface of the platysma can be shaved more accurately, yielding a more precise lipectomy. There are few descriptions of liposhaving in the neck ^{Article - Article} and only sporadic reports of endoscopic use in neck recontouring. ^{Article , Article} To our knowledge, this is the first report of use of both modalities together.

In the induction room with the patient in the upright position, a marking pen is used to reference the submental crease, sternocleidomastoid muscles, mandibular line, hyoid bone, thyroid notch, sternal notch, and external jugular veins. Once in the operating suite, a local anesthetic consisting of approximately 15 mL of 1% xylocaine with 1:100,000 epinephrine is administered throughout the neck. Monitored intravenous sedation is generally used; however, in some cases local anesthesia alone suffices for isolated neck recontouring.

A 2-cm incision is made just posterior to the submental crease in the midline. Face-lift scissors and a sharp, wide 2-prong skin hook are used to raise a skin flap, leaving a small amount of fat on the flap. The flap extends laterally to the sternocleidomastoid muscles, inferiorly to the thyroid notch, and superiorly to the mandibular line. The microdebrider (ESSential Shaver System, Smith & Nephew Richards, Inc, Bartlett, Tenn) is set in the oscillating phase at 2500 Hz with a 4-mm aperture in the blades. A 30° 4-mm rigid telescope (Karl Storz Endoscopy–America, Inc, Culver City, Calif) similar to that used for sinus surgery is passed with a Storz small-flap sleeve retractor. Videoendoscopy magnifies and illuminates the field. The fat to be removed is deep to the superficial skin flap and superficial to the platysma muscle ( Article , A) and is clearly visualized when the flap is retracted. The oscillating blades must be always visible and never buried in the tissue ( Article , B). The midline fat is shaved first until the platysma is directly visualized on the monitor. The fat is then shaved from medial to lateral and from superficial to deep. Care must be taken not to cut the muscle with the shaver. In this series of patients operated on with endoscopes, however, if the blades came in contact with muscle, rotation would cease.

Dissection is limited superiorly to the mandibular line, inferiorly to the thyroid notch, and laterally to the anterior border of the sternocleidomastoid muscle. The shaver is not used to remove fat in the midline between the platysma muscles or above the mandibular line. Blood is suctioned by the microdebrider and any persistent bleeding controlled with endoscopic electrocautery. The skin flap is then inspected with the endoscope and any irregularities of fat carefully shaved. The goal is to leave a uniformly thin plane of fat deep to the dermis and another thin layer superficial to the platysma muscle to avoid dimpling, retraction, or irregularity ( Article , C). The muscle is plicated down the middle with a running 3-0 polyglactin suture and the skin closed with an interrupted nylon suture. Skin is not excised since the dead space created by fat extraction will require skin for neck recontouring. As required, face-lift, midface suspension, and chin implants can be performed concurrently. No neck suspension sutures, slings, or drains were required for this group of patients. Compression dressings are used for 3 days, with replacement after the first day. A night sling garment is worn for the first postoperative month.

Between February 7, 1997, and October 2, 1998, 5 patients underwent endoscopic liposhaving for neck recontouring with platysma plication. No suspension sutures, slings, or anterior skin excisions were required. None of the patients had undergone previous facial or neck surgery. Concurrent procedures included transconjunctival blepharoplasty (patient 1 [ Article ]), face-lift (patient 3), and septoplasty (patient 4). Two patients required no adjunctive procedures (patients 2 [ Article ] and 5). All results were very good, with adequate fat removal and no significant asymmetry, dimpling, hematoma, or facial nerve injury. Patient and surgeon in all cases were pleased with the results.

Compared with current liposuction techniques, endoscopic liposhaving offers a more precise, accurate, and less traumatic modality for neck recontouring. Endoscopy combined with soft tissue shaving affords better visualization, allowing more precise extraction of fat.

The shaver is an ideal tool for lipectomy in cervical recontouring. Soft, fatty tissue is easily suctioned into the aperture of the oscillating blades, which then cleanly cut the fat. The endoscope ensures safe operation of the shaver, providing direct visualization of the blades through minimal incisions. The combined modalities in this series provided optimal results, with the endoscope facilitating complete, safe, and secure shaving of the contours of the platysma muscle, skin flap, and boundaries of dissection.

Liposuction has undergone significant modification since its introduction in the United States in the 1980s. The tumescent technique advocated by Klein ^Article is now standardly used for body liposuction when extracting large volumes of fat and for liposuction of the neck. Other adjunctive techniques that are gaining popularity include external ultrasound for body sculpturing ^Article and, for the neck, Giampapa and Di Bernardo's suture suspension technique ^Article as well as the use of e-polytetrafluoroethylene slings. ^Article

Gross et al ^Article introduced liposhaving for facial plastic surgery in 1995, describing it as a precise and less traumatic alternative to conventional liposuction, with the advantages of shaving in an open field under direct vision without a vacuum seal. In 1996, Becker et al ^Article presented results of a multi-institutional study demonstrating additional advantages of direct lipectomy with the liposhaver over liposuction. Becker and colleagues ^Article subsequently in 1999 reported their results of 3 additional years of study that demonstrated that the liposhaver continues to offer a precise alternative to liposuction.

The microdebrider, or soft tissue shaver, has led to significant breakthroughs in other areas outside of plastic surgery. Shavers were first used in arthroscopy and later adapted for sinus surgery. They rapidly became the criterion standard of soft tissue instrumentation in the 2 specialties. Several companies now manufacture microdebriders, including Xomed-Medtronics (Jacksonville, Fla), Stryker Corp (Kalamazoo, Mich), Linvatec Corp (Largo, Fla), and Smith and Nephew Endoscopy (Andover, Mass), and others have produced or are in the process of adapting blades for liposhaving.

The popularity of endoscopic facial plastic surgery has steadily grown. The endoscope is now a well-established tool in the armamentarium for upper-third facial surgery, including endoscopic brow lift. ^Article Telescopes are being advocated for use in midface lifts, ^Article but neck use has been mentioned only sporadically. In 1997, Ramirez ^Article reported using endoscopes in conjunction with nonexcisional anterior cervicoplasty, in the subplatysmal plane or laterally for dissection over the sternocleidomastoid muscle when required. Also in 1997, Keller and Hutcherson ^Article described a percutaneous neck lift using suture suspension that was approached through anterior and posterior incisions and visualized with an endoscope. However, there are no prior reports, to our knowledge, of concomitant use of an endoscope with the liposhaver for neck recontouring.

Compared with conventional liposuction, endoscopic liposhaving is less traumatic to the skin and surrounding tissues for a number of reasons, including lower suction pressure and a more controlled extraction. This contrasts with the quick back and forth tunneling movement of the liposuction cannula that is attached to a high-pressure vacuum. In addition, liposhaving avoids the significant swelling that accompanies hydrodissection with the "wet" tumescent technique. Endoscopic liposhaving permits visualization of any bleeding under the flap, which can be controlled before closure. The result is a more accurate and safe lipectomy, with less hematoma, swelling, and bruising.

The surgeon faces a learning curve in endoscopic procedures when any new instrument is used. Significant expertise in eye-hand coordination is required with the endoscope and shaver, but manipulation of the 2 generally improves with performance of more endoscopic techniques. The shaver is a cutting instrument that demands direct visualization of the blades. There is a risk of cutting through muscle or violating the subplatsymal plane, although in this series of patients, if the shaver encountered muscle, the blades jammed and ceased rotation. This is because muscle does not yield any free edge that can be suctioned into the aperture for the oscillating blades to cut. The jamming is due to its inability to cut the thicker, firmer muscular tissue. Also, muscle does not yield a free edge to be suctioned into the aperture for the oscillating blades to cut. Finally, endoscopic liposhaving equipment is expensive, although today most physicians and hospitals have videoendoscopy equipment with telescopes and microdebriders. The only additional expense is the onetime use of disposable oscillating blades, which cost less than $80. However, also to be considered is the training required to develop the expertise for using a cutting instrument and angled endoscope, understanding their function, and appreciating the limitations of their use.

As with any procedure, a thorough understanding of the regional anatomy is required to safeguard vital structures in the area of dissection. If the shaver is kept in the subcutaneous plane, there is little danger of injuring major vessels or nerves. If dissection progresses above the mandibular line, the marginal nerve is at increased risk. If the platysma muscle is violated or if dissection approaches deep to this structure, facial nerve branches, arteries, and veins are at increased risk. Gross ^Article and Becker ^{Article - Article} and their colleagues have successfully used the liposhaver in the higher risk areas by leaving the blades in the open position without rotation. This mode simulates conventional liposuction with its open-tipped cannula, suction, and recessed blades.

By combining endoscopy with a soft tissue shaver, a more precise, less traumatic lipectomy can be obtained in the neck compared with conventional liposuction. Endoscopic liposhaving has the potential to enhance neck recontouring and improve the mandibular line and mento-hyoid angle. To our knowledge, this is the first report of concurrent use of these modalities in neck recontouring. The enhanced visualization should make endoscopic liposhaving a useful addition to the armamentarium for neck recontouring.

Accepted for publication March 23, 2000.

Reprints: B. Todd Schaeffer, MD, 3003 New Hyde Park Rd, Suite 409, New Hyde Park, NY 11042 (e-mail: LIFacialMD@aol.com).