Localized adiposity may be attributed to hereditary factors, hormonal imbalance, or poor dietary and exercise habits. Evenly distributed fat stores, unlike isolated facial deposits,8,10° diminish with exercise and diet. Frequently and unfortunately, the localized deposits are the first to hypertrophy with weight gain.
Illouz, one of the pioneers in liposuction, did extensive studies on the physiology of the human adipocyte. He was determined that human adipocytes multiply from birth until puberty and then are stable in number. Based on histologic study, he described obese children as having a large number of adipocytes (a hyperplastic state) versus the obese adult simply having "large" fat cells (a hypertrophic state).1 Through the incorporation of triglycerides and fatty acid deposits, the overall volume of the fat cell increases. Weight loss is a reduction not in the number of fat cells but rather in their volume.4,11 Surgical intervention should be directed at eliminating localized fat cells, ideally in a permanent fashion. Recreating an aesthetic contour by reducing unattractive fat deposits is the underlying goal and function of suction lipectomy.
The majority of new technological interventions, with one exception, take seed from body contouring research, which can frequently be applied to facial surgery. The use of a rigid, blunt-tipped aspiration cannula that is attached to a suction device continues to be the mainstay for suction lipectomy.
Inconspicuous cervicofacial liposuction incisions may be placed in the submentum, the infralobular crease, the nasal vestibule, and the temporal hairline. Recontouring of the overlying soft-tissue envelope is achieved through elimination of fat cells by suction-assisted avulsion and by subdermal contraction seen during the healing phase. Changes have been seen in the mode in which the fat cell is mobilized-by the addition of the tumescent technique, ultrasound technique, or with simple mechanical disruption.
Traditional liposuction permits a relatively precise reduction in fat cell mass coupled with a low complication rate as compared with direct lipectomy.2,7,18 Because with liposuction the neurovascular bundles to the skin are preserved, there is less bleeding and hematoma formation. A limitation of liposuction is seen in its incomplete removal of deeper midline submental fat that frequently requires direct midline excision. Recontouring takes place as healing progresses, with contraction of the subcutaneous tunnel network created by the liposuction tunneling technique. With a carefully designed and evenly distributed tunnel system, bulges and irregularities secondary to localized fat rarely recur. Early healing irregularities may be seen but are usually fleeting. 5,8,12-14
Suction-assisted lipectomy (SAL) demonstrates numerous advantages over techniques designed for direct fat excision. SAL eliminates the need for large incisions, reduces operative and recuperative time, and rarely if ever causes permanent injury to nerves. 5,8 SAL allows preservation of the neurovascular bundles to the skin through the tunnel network. Preservation of neural input means less numbness. By selecting patients with good skin elasticity and localized adiposity, and by using the appropriate operative and postoperative techniques, patients will be happier and the aesthetic results should be improved.
This chapter presents guidelines for the selection of appropriate candidates for liposuction. It will review the physiology and technique of liposuction, highlight necessary equipment, and suggest ways to avoid complications. Finally, most recent advances in the field are discussed.
