Submental liposuction and deoxycholic acid injections are both used to reduce excess fat under the chin, often called a double chin[1]. In phase III trials, deoxycholic acid injections reduced moderate to severe submental fat compared with placebo, using as many as six treatments given at least one month apart[2]. For submental liposuction, a systematic review of 2,085 aesthetic cases found an adverse event rate of 12.9% per procedure, with most events minor[3]. Neither option suits everyone: not every patient with submental fat is suitable for the injections[2], and one review argued that isolated liposuction benefits only a select group of cosmetic patients[4].
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Liposuction is an invasive way to contour the area under the chin, while deoxycholic acid is an injectable drug approved in the United States and Canada for reducing submental fat[1]. Excess fat in the submental area is what many people call a double chin, and it can negatively affect facial esthetics and body image[1].
Deoxycholic acid is a secondary bile acid, a substance involved in breaking down dietary fat, and when injected into the fat under the skin it causes fat cells to break apart[2]. Deoxycholic acid was the first fat-dissolving substance approved by the US Food and Drug Administration for reducing fat in the submental area[5]. Researchers describe deoxycholic acid injections as an in-office procedural alternative to submental liposuction or submentoplasty[6].
Aesthetic submental liposuction is a widely performed procedure for contouring the lower face and the front of the neck[3]. Submental liposuction can be done under local anesthesia, and one surgeon reviewed 695 patients treated this way between October 2020 and August 2022[7]. For liposuction in general, local anesthesia avoids the specific risks associated with general anesthesia[8]. You can read more about the procedure itself in our overview of neck liposuction.
For the injections, a meta-analysis of five randomized trials with 1,838 participants found that deoxycholic acid improved every efficacy measure compared with placebo[9].
A systematic review of six prospective studies, covering 3,488 patients with average ages from 46 to 49.5 years, found less submental fat and higher patient satisfaction with deoxycholic acid than with placebo at the end of a 12-week period[10]. Five phase III, randomized, double-blinded trials enrolling more than 1,700 patients showed improvement on scales rated by both clinicians and patients, with skin caliper measurements and MRI scans providing objective evidence[11].
In the phase III trials, the benefits of deoxycholic acid generally came without worsening skin laxity and were largely maintained over extended follow-up, such as two years after treatment[2]. A meta-analysis that looked for industry influence found that all five included trials showed potential industry bias, that only two had a low risk of bias, and that the certainty of evidence was low to moderate[12].
Based on 695 patients treated under local anesthesia, one surgeon concluded that submental liposuction is efficient and has very low drawbacks[7].
A literature review comparing liposuction techniques found that laser-assisted liposuction gave more skin tightening than standard suction-assisted liposuction in select areas, specifically the submental area[13]. Outside a few exceptions, that review found no clear benefit of one liposuction technique over another[13].
Liposuction alone does not address every cause of fullness under the chin, according to a review that favored formal cervicoplasty, combining open liposuction with platysmaplasty, over isolated liposuction[4]. Aging changes in the front of the neck can include skin laxity, accumulation of submental fat, platysmal banding and drooping of the underlying neck structures[14].
Deoxycholic acid was given as a course of sessions in trials, with up to six treatments spaced at least one month apart[2]. A review of phase III trials described monthly injections over four to six treatment sessions[11]. In the phase III trials, a single treatment could comprise up to fifty injections[2].
In the placebo-controlled studies of one systematic review, the interval between applications of deoxycholic acid was 28 days in every study[10]. The authors of a review on serious adverse events recommend assessing the thickness of the fat pad to determine how many treatment cycles a person needs[15].
In one surgeon's series of 695 submental liposuction patients, the most important complication, irregularity, could be managed by massage and ultrasound treatment[7]. If you are considering liposuction, ask your surgeon whether a touch-up might be needed in your case and what that would involve.
Pain, swelling, bruising and numbness are common after the injections, while seromas, skin irregularities and platysmal banding were the most reported minor problems after submental liposuction[11][3].
Pain at the injection site is the most common adverse event of deoxycholic acid, occurring in more than 80% of treated patients[11]. Other common adverse events of deoxycholic acid include swelling, bruising, numbness and induration[11].
The side effects of deoxycholic acid usually involve the treatment area, are mild to moderate in severity, and resolve within approximately one treatment interval[2]. In a meta-analysis, withdrawals due to adverse events were 6.8% with the lower dose and 9.9% with the higher dose of deoxycholic acid, with no difference between the two[9].
Compared with placebo, patients treated with deoxycholic acid had a higher risk of fibrosis, pain, erythema, numbness, swelling, edema, pruritus, nodules, headache and paresthesia[12].
Across 13 studies covering 2,085 aesthetic submental liposuction cases, a systematic review identified 270 adverse events, an event rate of 12.9% per procedure[3]. Minor events made up 74.8% of the complications in that review, led by seromas, skin surface irregularities or asymmetries, and platysmal banding[3].
In that systematic review, the mean time to onset of adverse events after submental liposuction was 1.7 months, and most events could be managed in outpatient settings[3]. The authors of that review noted significant limitations in the evidence and called for better-designed studies[3]. For liposuction in general, the most common complications are contour irregularities and transient bruising[8].
In a prospective randomized study of 29 submental liposuction cases, a fibrin sealant, which is a tissue adhesive, led to significantly less postoperative swelling than no sealant[16]. Our guide to swelling and seroma after liposuction covers recovery in more detail.
Nerve problems have been reported after both treatments, and reviews describe them among the rarer complications[17][18].
Numbness is among the most common side effects of deoxycholic acid in clinical trials, where it was transient and mild to moderate in severity[18]. Reviews list nerve injury, including transient neuropraxia, among the less common complications of deoxycholic acid reported beyond the clinical trials[5][18].
In an analysis of the MAUDE adverse event database covering 21 events from 13 reports, marginal mandibular nerve weakness accounted for 4 events (19%) and numbness for 3 events (14%)[6]. To check whether the marginal mandibular nerve is close to the injection area, one review recommends a lidocaine test injection and watching for smile asymmetry[15].
A scoping review of submental liposuction complications listed transient facial nerve paralysis, along with submental depression, submental edema, hypertrophic scars, scar contracture, cervical necrotizing fasciitis and cervico-facial dystonia[17]. That scoping review included only four studies out of the 539 articles first selected[17].
In patients who had submental liposuction combined with orthognathic (jaw) surgery, a systematic review of 67 patients listed sensory changes in the lower lip (n = 4) and facial nerve injury (n = 2) among the most cited complications[19]. If numbness worries you, our article on numbness, burning and nerve pain after liposuction may help you prepare questions.
Serious complications are reported for both options: bleeding-related complications, including fatalities, after submental liposuction, and skin necrosis, alopecia and vascular events after deoxycholic acid[16][5].
In the MAUDE database analysis, skin necrosis accounted for 3 of the 21 events, and two patients required hospitalization for it, both with underlying systemic diseases[6]. Other events in that analysis included excessive swelling in 5 events (24%), an unsatisfactory aesthetic outcome in 4 events (19%), and one event each of dysphagia and infection[6].
A systematic review of serious adverse events after deoxycholic acid found that most were procedure related and avoidable[15]. That review recommends avoiding intradermal injections to prevent skin ulceration or necrosis, and using good aseptic technique to prevent abscess formation[15]. One review urges dermatologists to be aware of these risks, including in patients treated with deoxycholic acid outside the medical clinic environment[18].
For submental liposuction, the scoping review described a patient with a submental hematoma after the procedure who had no sequelae[17]. If you notice rapidly growing swelling, trouble breathing or swallowing, fever, or darkening skin after either treatment, contact your surgeon or emergency services right away.
For surgical correction of the area under the chin, one review says the surgeon must first diagnose the anatomic irregularities before recommending a procedure[14]. Because neck anatomy varies widely among individuals, surgery in this area needs to be customized for each patient, using a single isolated procedure or multiple techniques[14].
Deoxycholic acid is indicated for adults with moderate to severe convexity or fullness from submental fat, and patient selection is key to achieving the desired aesthetic outcome[2]. Before injecting, one review recommends investigating other possible causes of submental fat accumulation and of jowling[15]. That review states that surgery is preferable for jowling caused by drooping tissue, and that fat-reducing injections are contraindicated for jowling caused by thinning of the tissue under the skin[15]. In men, the same authors advise injecting slightly deeper to help prevent alopecia[15].
Isolated liposuction is only beneficial in a select group of cosmetic patients, according to a review that judged formal cervicoplasty a superior operation[4]. Liposuction does still have a role in cosmetic surgery of the submental area, the same review noted[4]. Our page on whether you are a liposuction candidate covers the general questions to think through.
A consultation with a board-certified surgeon is the place to weigh these options for your own chin and neck. Questions worth asking include:
In phase III trials, the reduction in submental fat after deoxycholic acid was largely maintained over extended follow-up, such as two years after treatment[2].
Pain at the injection site is the most common side effect of deoxycholic acid, occurring in more than 80% of treated patients[11]. Adverse events of deoxycholic acid were very common but transient and localized to the treatment area[11].
In a systematic review, tumescent or local anesthesia was the most common type of anesthesia reported for aesthetic submental liposuction[3]. One surgeon reported 695 patients who had submental liposuction under local anesthesia[7].
In randomized trials, side effects of deoxycholic acid were predominantly transient and usually at the injection site[9]. A review of submental liposuction case reports and case series found an adverse event rate of 12.9% per procedure, with most events minor[3]. A board-certified surgeon can help you weigh these risks for your own anatomy.