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The goal of liposuction regardless of methodology is to recontour areas of adiposity by precise reduction in localized collections of fat while minimizing external irregularities or scars. The technique looks relatively easy and is not difficult to perform. Several details of the procedure, however, must be appreciated to obtain an optimal result and to ultimately produce smooth-surface contours and minimize the chance of any postoperative problems.
Accurate overall reduction of cervicofacial fat is essential. The face and neck are not areas that are easily camouflaged, so that use of techniques to create as symmetrical a result as possible is important. Underestimating the amount of fat reduction necessary to meet aesthetic goals may be the lesser of two evils-the greater evil being overaggressive fat resection with creation of an unnatural concavity or hollowing. If too much fat is removed, unmasking of platysmal banding may result, requiring an open plastysmaplasty with or without facelift to correct the problem (Fig. 19-6).
Figure 19-6 Unmasking of the platysmal bands (A) and masculinization (B) of the thyroid notch after overaggressive submental liposuction. (From Kridel RWH, Pacella BL. Com-plications of liposuction. In Eisele D (ed). Complications of head and neck surgery. St. Louis: Mosby-Year Book, 1992:791-803. With permission.)
For example, overaggressive fat liposuction in the cervicomental region in the female rhytidectomy patient may create a masculinized appearance by skeletonization of the thyroid notch. Skeletonization here creates a "pseudolaryngeal prominence," characteristic of the male neck.
Cervicofacial liposuction may be performed in an open or closed fashion. If the patient's optimal aesthetic result would be obtained with the addition of a facelift, a combination of the closed and open techniques may be in order.
Liposuction as a Primary Procedure
Incisions in the submental crease, in the posterior lobular crease, or in the nasal vestibule are well hidden and give excellent access to the entire cervicofacial region. If internal ultrasonography systems are being used, the incision may require greater length to allow for insertion of the slightly larger cannula and the skin-protecting unit. Too small an inci-sion regardless of technique may predispose to friction burns or skin excoriation at the incision site, simply from the back-and-forth motion of the suction cannula. The incision is gen-erally 4 to 8 mm long. The incision should accommodate a 4- or 6-mm cannula, (i.e., the largest cannula diameters suggested in cervicofacial liposuction procedures.5,8,41 The incision is created and the immediate surrounding skin is sharply undermined with a small tenotomy scissors to allow appropriate placement of the cannula in the proper plane and to prevent postoperative irregularities at the incision site. The appropriate plane is just deep to the dermal-subcutaneous interface. Pretunneling (passage of the cannula through the area to be treated without suction pres-sure) is frequently done prior to active aspiration. The proper plane in the fibrotic or previously operated neck is elusive, and pretunneling is helpful in ensuring proper dis-section depth. Once the dissection is initiated, the aspiration cannula is introduced through this site. Suction pressure should be briefly suspended each and every time that the cannula is removed from or inserted into the incision site so as to decrease the potential for entrance site injury from the suction pressure. An assistant or scrub technician should focus attention on this task, thus allowing the surgeon to concentrate on the task at hand. A simple pinch of the suc-tion tubing and release technique is adequate to prevent entrance site injury.
Entrance of the cannula lumen through the incision site is done in such a way that the lumen opening is always directed toward the subcutaneous tissues and away from the dermis. When performing liposuction in the cervicofacial region, there are few if any indications for, directing the cannula lumen aperture to the dermal surface.18 Vigorous suction against this surface may cause injury to the subdermal plexus, with the result being scar formation and significant postoperative irregularities.
Lipoextraction begins by pretunneling the lipodystrophic site with a spatulated single-lumen 2-, 3-, or 4-mm liposuction cannula. These cannulas are the "workhorses" of cervical liposuction. When addressing the submental liposis, the dissection will fan across the neck from jowl to jowl. The tunnels will circumscribe an arc that extends to the stern-ocleidomastoid muscles laterally and to the thyroid cartilage inferiorly. The radiating tunnels will fulcrum or center at the incision site in the submental crease (Fig. 19-7).
Figure 19-7 (A,B) The liposuction cannula is inserted (with its fulcrum at the center of the submentum) and advanced in a fan-type pattern toward the sternocleidomastoid muscle. The skin is tented upward with the cannula so as to maintain a superficial dissection plain to avoid injuring deeper sutures. (C) An incision is placed just posterior to the earlobe and the cannula inserted to criss-cross the neck dissection. Care to be conservative is necessary if the cannula is brought over the mandibular angle to approach the jowl. (D) When a facelift is planned, liposuction cannulas can help dissect the flaps. Skin flap elevation after liposuction dissection shows the creation of a network of subcutaneous tunnels. (E) Tunnels created by the advancement and retraction of the cannula within the submentum allow preservation of the neurovascular network. (From Kridel R, Konior R. Suction lipectomy. In: Krause CJ (eds). Aesthetic facial surgery. Philadelphia: JB Lippincott, 1991. With permission.)
The most vig-orous suction should be performed in the area of greatest liposis, delineated by preoperative marks. The larger cannulas (3-, 4-, or rarely 6-mm) are then used here for fat volume reduction, but they may be too large and are not appropriate for all patients, especially those with minimal or moderate fat deposits. Sculpting with a blunt-tipped small-lumen cannula may allow for added definition at the mandibular border or full-neck dissection in those with minimal fat deformities. Liposuction more distal to the primary sites of concern should be aimed at blending or feathering the newly recon-toured area. Feathering is best accomplished with use of a smaller lumened cannula having a single or double aperture.
After pretunneling is accomplished, the cannula is con-nected to the suction device. Fat is removed by directing the cannula throughout the pretunneled area in the same radially directed manner used initially. The relatively atraumatic tunnel system preserves neurovascular and lymphatic continuity between skin and deeper subcutaneous tissues. A superficial tunnel is maintained by tenting the skin away from the deeper tissues with the cannula tip. The left hand (for the right-handed surgeon) is the dominant one during this procedure. It serves to guide the cannula, direct the fat into the lumen, and maintain the correct tissue plane. The right hand is the motor, advancing the cannula through the space. Evenness of cannula motion and a fan-type pattern ensures the correct dissection plane and even fat extraction. Fat extraction continues in this preplatysmal plane until the desired result is achieved. As the main fat accumulation is removed, sculpting and feathering are performed with smaller and less aggressive cannulas. Numerous cannula choices exist for this purpose; the authors prefer a single- or double-aperture 2-mm spatulated cannula.
Redefining the jaw line may necessitate two additional incisions, one behind each ear lobe, hidden in the infralobular crease. These incisions should be vertically oriented and just long enough to accommodate a 2- or 3-mm cannula. Development of the subdermal dissection plane is again initiated with use of a small scissor and pick-up. The 2- and 3-mm cannulas may have one, two, or three suction apertures. The more aggressive has multiple openings and may be used initially for greatest fat extraction. Feathering with the single or double-aperture cannula will create better postoperative contour.
The lateral infralobular approach, in addition to the submental approach, allows better access to the area below the mandibular angle. This multidirectional approach creates an extensive overlapping subcutaneous tunnel network that encourages maximal contour enhancement. As the cannula is advanced into the subdermal plane, the arc-and-fan technique is used. Care should be taken to ensure that the cannula lumen is never directed upward, that suction in this closed setting is performed only below the angle of the mandible in most situations, and that suction pressure is suspended when the cannula aperture is inserted or withdrawn from the incision site. Some feel that in the fatter face, the surgeon can judiciously extend the liposuction area up over the mandible with very small cannulas.
Frequent inspection of the site and use of the pinch-and-roll technique helps the surgeon to avoid overextraction. In this maneuver, the skin is gently pinched between the thumb and forefinger and rolled. A sufficient amount of fat has been extracted when the surgeon can feel a thin layer of adipose tissue remaining between the opposing deep surfaces. Extraction volumes vary from person to person, but most require 10 to 100 cm3.
Occasionally, fat deep to the surface of the platysmal muscle is responsible for loss of the youthful cervicomental angle. In these cases, the cannula can be directed to the deeper plane through the submental access site. Removal of fat here poses little risk to neural structures, such as the marginal mandibular nerve, but small-vessel injury is possible. Cannula direction should stay within the central midline to avoid neural injury more laterally. In facelift patients, the authors have often followed what was thought to be effective and aggressive neck liposuction with open inspection and have found much fat still left in the midline, which required open excision. The liposhaver may ultimately provide a solution in this area, but the submental midline can be a vascular area and care must be exercised.
If direct lipectomy is necessary in the midline, then under direct vision additional fat may be excised. Excision may be performed with scissors or with the use of the liposhaver. More definitive undermining and a slightly larger incision are required for sharp lipectomy, and neurovascular bundles are sacrificed. The undermining can be done with the facelift scissors or the suction bovie cautery on a low setting. If using the cautery to complete flap undermining, the overlying skin is tented away and protected with the Converse retractor. The plane of dissection is then developed under direct vision.
Addressing the lower fullness in the jowl area with lipo-suction as the primary procedure should be done with extreme caution. The posterior earlobe-crease incisions will allow access to this area. Unless the entire region between the incision site and the fat collection is to be contoured, suction should not be applied until the cannula tip enters the offending adipose deposit. Failure to observe this detail may result in an obvious linear depression between the incision site and the distant fat pocket.
When deciding on jowl fat extraction, patient selection is of utmost importance. The patient with excess skin and poor elasticity will be left postoperatively with unattractive bags of skin where once there was fat. Even in the appropriately selected younger person, excess fat extraction may result in concavities that will only worsen with age as facial fat atrophies.
Isolated liposuction of the midface alone can be disastrous if overaggressive suctioning is carried out, creating marked depression and visible irregularities that are difficult to correct (Fig. 19-8).
Figure 19-8 Overaggressive isolated liposuction of the buc-cal midface area caused marked depressions that necessitated a facelift with acellular dermal sheeting implants and injections for correction. (See also Fig. 19-12.)
Conservative suctioning of full nasolabial mounds may be helpful and can be accomplished with small cannulas via an intranasal approach.
The surface contour of the neck must now be carefully inspected before the procedure can be concluded. Dimpling generally implies residual attachments between the subcutaneous fat and overlying skin. Release of these isolated attachments usually resolves the problem. Subtle platysmal banding that may not have been evident preoperatively may now be more noticeable. Through the submental incision these bands may be plicated with or without direct excision to prevent, postoperative visibility. If the bands are anticipated preoperatively, the fat extraction may be tempered to prevent increased notice. Lengthening of the submental incision may be necessary to allow suture closure of the diastatic platysmal muscles. Lengthening of the incision should entail a gentle lateral curve so that the incision does not relocate up over the mandible with healing.
After the procedure is complete and final assessment (by pinching and rolling the skin between the fingers) reveals good symmetry, the incision sites are closed in layers with 6-0 stitches and the wounds covered with antitension tape.
The dissection pocket is milked to ensure that no blood collects and no loose fat globules remain. In patients with larger fat volume removal, and prior to closure, irrigation of the area may be carried out to remove as much loose or liquified fat as possible to prevent postoperative irritation. Closed liposuction as a primary procedure does not require suction drainage but does require a light pressure wrap to reduce tissue edema and to immobilize and reshape the skin over the recontoured soft-tissue facial framework. More pressure should be applied if direct sharp lipectomy was also required. The skin overlying the dissection is first covered with a smooth piece of cotton or Telfa (Kendall Company, Mansfield, MA) and then may be wrapped with Kerlix (Johnson and Johnson, Arlington, TX) gauze. The dressing is completed with either Coban (3M Healthcare, St. Paul, MN) elastic dressing or a facial sling. The elastic sling is comfortable, may be repositioned, and allows easy access to the surgical site. The patient is instructed to limit head and neck mobility for 36 to 48 hours to allow reattachment of the skin to the underlying soft-tissue bed.
Liposuction as an Adjunctive Procedure
Choosing the appropriate candidate for liposuction may also entail selecting a different primary procedure and using liposuction as a secondary or refining technique. Although the patient's purpose in seeing the doctor may have been to have a discussion about liposuction, the surgeon may need to explain why a better avenue for facial rejuvenation may be, for example, chin augmentation, rhytidectomy, or platysmaplasty. Appropriate patient evaluation for an optimal surgical result is extremely important, and the skills involved in this must be learned and reinforced with each and every patient visit.
Liposuction Combined with Chin Augmentation
When microgenia or retrognathia (two different entities) coexist with submental liposis, results of chin augmentation or orthognathic surgery, or submental liposuction alone, are less than optimal. When combined, the result may be dramatic (Fig. 19-9).
Figure 19-9 (A) Preoperative. Patient with submental fullness, microgenia, and young elastic skin. (B) Favorable postoperative result from submental liposuction, nasal surgery, and chin augmentation.
The overlying goal is recreation of the acuity of the cervicomental angle. Patients who have a recessed chin or low and anterior hyoid position are those who benefit from extraction of submental fat and increased projection of the chin.
Placement of the incisions for a combined submental liposuction and chin augmentation procedure is similar to that for liposuction as a primary procedure, with one exception. If the chin is augmented from an external approach, the submental incision is extended slightly to accommodate the chin implant. If the surgeon prefers, a separate gingivolabial incision may be used for placement of the implant through the oral approach. In this case, care should be taken to keep the two surgical sites-chin and submentum-separate from one another. Salivary contamination of the neck is an unwanted outcome. The tendency for intraorally placed implants is to migrate superiorly, whereas those implants placed externally are apt to fall inferiorly, creating a witch's chin deformity. Suture fixation and precise pocket techniques are helpful in maintaining chin implant position.
Liposuction-Assisted Rhytidectomy
Liposuction can significantly enhance the results of rhytidec-tomy by removing the unwanted fat not only in the submentum but in the pretragal and jowl areas as well. The benefit is seen with the addition of this technique in its ability to recontour with little risk to underlying neurovascular structures. Fat removal prior to the advent of liposuction from areas such as the jowls was either not done or was looked on unfavorably because of the risk of neural injury or contour irregularity that could result from overaggressive suctioning or tracking. Access to the jowl region was difficult from the standard facelift incisions, and the thought of additional incisions was, antithetical to the well-concealed-incision techniques of established facelift protocols.
Three key maneuvers are required to fully appreciate the benefits of liposuction during a facelift. First, closed liposuction is used to reduce the prominent facial fatty deposits with minimal bleeding. Next, the cannula, with or without employment of the suction, facilitates facial flap elevation. Finally, open liposuction fully refines the region under direct visualization
The standard closed-liposuction technique is used first to remove any prominent adipose accumulations in the submental, submandibular, and jowl regions. The incision in the submentum is 5 to 8 mm long, and the initial dissection is initiated with use of a small scissors. A 3- or 4-mm cannula may be used for initial fat extraction, with pretunneling helpful but not absolutely necessary. Infralobular incisions and preauricular incisions allow further access to facial fatty deposits, with the understanding that excess skin will be addressed in the rhytidectomy part of the procedure. Despite this fact, a conservative approach to fat extraction in the midface and jowl regions is still recommended. Unwanted postoperative irregularity or depressions can result from overaggressive midface liposuction (Fig. 19-10).
Figure 19-10 (A) Postoperative result from outside institution (front view). Patient with concave deformity in the inframalar area from overaggressive midface liposuction during facelift procedure. (B) Postoperative result from outside institution (lateral view). Poor patient result after bilateral lower jowl liposuction with resultant concavity and laxity to skin.
After reducing the bulk of the cervicofacial adipose accumulations with the closed technique, undermining of the facial flaps is completed with the standard scissors technique. Undermining after use of the blunt-tipped cannula in the closed liposuction technique is easy and quick. The subcutaneous bands created with the tunneling technique of liposuction are simply identified and divided, and flap elevation is finished. The relatively atraumatic nature of this blunt dissection process allows undermining to proceed up to the nasolabial fold without concern for neurovascular injury.
After flap elevation is complete, initial flap inset incisions are created, and plication or imbrication of the SMAS or a deep-plane lift (surgeon's choice) is performed. Open liposuction may be used as a refining final step. Usually, a blunttipped 4- or 6-mm cannula is chosen, and any areas of fullness or irregularity are addressed. A spatula-shaped tip maximizes contact between the suction cannula and the soft-tissue bed, which is required to maintain a seal with continuous suction in an open environment. Unwanted fat deposits are removed by placing the suction cannula aperture directly on the subcutaneous bed and moving it rapidly with a to-and-fro motion along the open face of the dissection pocket. Lipo-suction before plication or embrication in the pretragal/ preauricular area can be used to ensure less immediate post-operative fullness in the area where much of the SMAS is secured with resuspension sutures. After final assessment is performed to determine whether additional liposculpting is necessary, the remainder of the rhytidectomy, including skin excision, should proceed in a routine fashion (Fig. 19-11).
Figure 19-11 This patient had a combination of facelift and liposuction: (A) before and (B) 11 years postoperative.
Access to the jowl fat pad is also facilitated after the routine facelift flaps are developed; a very small (1- or 2-mm) cannula can be inserted under the facelift flaps directly into the jowl fat under direct visualization.
