The Isolated Submentoplasty

Non-surgical neck rejuvenation solutions are easy to incorporate into the aesthetic practice. But according to Randolph Waldman, M.D., a facial plastic surgeon in Lexington, Ky., the isolated submentoplasty is a minimal-incision surgical solution that quickly and effectively reduces submental fat and retracts the skin.

Importantly, it’s safe, repeatable and results in high patient satisfaction, he says.

“This is a small procedure we do in our practice that probably takes me about 20 to 25 minutes… it's one of the best ROI and best appreciated by our patients of the procedures that we do. The level of satisfaction with this procedure is very, very high. The complication rate is almost zero,” says Dr. Waldman, who presented “Submental Liposuction: The Poor Man’s or Poor Woman’s Facelift” at South Beach Symposium 2020 in Miami, Fla.

The concept behind this closed neck-lifting technique is not to remove excess skin, but to use liposuction with minimal incisions to remove fat, redistribute the skin and to allow the body’s natural fluids to “glue” things into a more youthful place.

“Dr. Feldman in Boston, a well-known plastic surgeon, preached this principle for years, which basically was not to remove any skin and to do minimal incision remodeling of the neck by redistributing the skin,” says Dr. Waldman.

Joel J. Feldman, M.D., is credited with being an early developer of small incision techniques for the face and neck and well known for his neck lifting results. He retired in 2015.

While the isolated submentoplasty is a tried-and-true approach for Dr. Waldman, there are several important considerations for a successful result, including skin elasticity, patient age, effective redistribution of the skin, cannula type and technique, anesthesia and incisional approach.

Of them all, “Skin elasticity is probably the most important consideration when you analyze a patient [for this procedure],” says Dr. Waldman.

While age is a consideration, it’s also necessary to evaluate patients on an individual basis, he says, as chronological age doesn’t always indicate skin quality.

“Aging can be a factor, but really in today's world, skin elasticity can be very poor in younger people or can be extremely good in some people well over the age of 45.”

As for anesthesia, Dr. Waldman prefers propofol. He says he uses it for everything from tummy tucks to breast reductions and augmentations. “But particularly with facial procedures we can pretty much do it all with propofol anesthesia.”

The specific cannula type is key to the technique.

“We use ‘accelerator-style’ cannulas,” says Dr. Waldman, “These are shorter cannulas designed specifically for the neck. I like the #3 and the #4, which have side ports that can actually be directed superficially.”

“I know that's not what we preach. We preach keeping the cannula turned down towards the fat and the muscle in most areas of liposuction. But in this case, we want to create some slight injury to the fat on the undersurface of the skin.”

Dr. Waldman points out that an open technique is possible and perhaps even necessary when faced with patients who have excess skin laxity. However, his preference is the closed technique, with three small incisions: first in the submental area, where a small tunnel is created with the cannula and behind each earlobe.

Once you’ve reached the end of the liposuction process, “It's very important to kind of pinch the skin across the neck to feel any irregularities or areas of persistent fat accumulation. Very carefully retract the skin laterally and you’ll see any dimpling or excess fat and you can correct that immediately,” Dr. Waldman says.

After closing the incisions with 6-0 nylon, comes the critical final step: After retracting and redistributing the skin, the dressing then holds it all together.

“As we put the dressing on, we're holding everything laterally so we can get things to heal in the proper position. This is a fairly tight dressing. We're not worried about perfusion here. We've elevated no significant flaps and so the dressing will be removed the next morning. We generally will put a garment on the patient for seven days fairly continuously except for showering and then again for another three weeks at night.”

One day post-op, it’s normal to have some ecchymosis and slight bruising, says Dr. Waldman, but you’ll already see how that patient’s skin has redistributed, along with a visible reduction in fat.

Skin redistribution and fat reduction results are immediately noticeable but remember, says Dr. Waldman, “As it is with any liposuction, this will improve over the next two or three months.”