Liposuction technique on the face and neck

The task of liposuction, regardless of the technique, is the restoration of the contour in the areas of fat deposits by targeting the reduction of limited accumulations of fat, while minimizing external irregularities and scarring. The technique of liposuction looks relatively simple and simple to use. However, in order to achieve optimal results, to create smooth contours and to reduce the likelihood of any postoperative problems, it is necessary to take into account some details.

Determine is a neat uniform decrease in the amount of fat on the neck and face. These areas are not easy to hide, so it is important to create the maximum possible symmetry of the contours. Underestimation of the amount of fat that must be removed to achieve aesthetic results may be less evil than unnecessarily aggressive fat removal with the formation of unnatural defilements or voidings. With the removal of too much fat, nasal traction of the subcutaneous muscle of the neck may occur, which in turn will require an open plasmic implantation, either in isolation or with a facelift, to correct this condition. For example, overly aggressive liposuction in the cervico-chin area of a woman undergoing rhytidectomy can create a masculine appearance associated with the skeletalization of the thyroid sirloin. Contouring of the tenderloin creates a "pseudo-oral ligament", characteristic of the male neck.

Liposuction on the face and neck can be performed in an open and closed way. If the optimal aesthetic result for the patient can be achieved by combining liposuction with a facelift, the right choice can be a combination of open and closed technique.

Liposuction as a primary operation

The incisions in the sub-chamomile fold, in the fold behind the earlobe or on the threshold of the nose are well disguised and provide excellent access to all areas of the face and neck. If a system for ultrasonic liposuction is used, longer incisions will be required to insert a larger diameter cannula and a skin protection device. Too small a cut, regardless of technique, can predispose to burns due to friction or to skin damage as a result of the reciprocating movements of the suction cannula. Typically, the cuts have a length of 4 to 8 mm. The incision should pass a cannula 4-6 ml in diameter (that is, the largest diameters suitable for liposuction on the face and neck).

After the incision is made, the skin immediately surrounding it is cut by small tenotomy scissors to install the cannula in the correct plane and to prevent postoperative irregularities in the region of the incision. The correct plane of the operative action is located immediately under the dermal-subdermal boundary. Often prior to the onset of active aspiration, preliminary tunneling is performed (holding the cannula through the area of interest without turning on the suction). In conditions of severe neck fibrosis or after previous operations, it is difficult to determine the correct plane, and tunneling allows to determine the correct depth of preparation. After the beginning of its implementation, the cannula is inserted through the incision. To reduce tissue trauma around the incision, suction must be temporarily turned off every time the cannula is removed or inserted into the incision. This should be followed by an assistant or an operating nurse, allowing the surgeon to concentrate on performing his task. To prevent damage at the access point, you can simply by squeezing and releasing the suction tube.

The cannula is inserted through the incision in the direction of the wound canal itself, that is, in the direction of the subcutaneous tissue and away from the dermis. When performing liposuction in the face and neck area, there is practically no indication for the direction of the holes in the lumen of the cannula to the surface of the dermis. Intensive suction at the inner surface of the dermis can cause damage to the subcutaneous plexus with the formation of a scar in the postoperative period and significant unevenness.

Lipoextraction begins by preliminary tunneling of the lipodystrophy region of a single-lumen cannula with a diameter of 2, 3 or 4 mm with an end in the form of a spatula. These cannulas are the "workhorses" of liposuction on the neck. When subjected to sub-chiropractic lipomatosis, the preparation is made fan-shaped across the neck, from one corner of the lower jaw to the other. Tunnels describe an arch that extends to the sternocleidomastoid muscles laterally and to the thyroid cartilage downward. The starting point of divergent tunnels is the location of the incision in the sub-chordial fold. The most intensive suction should be done in the area of the largest fat deposition, which is marked by pre-operational marking. Then, larger cannulas (diameter 3, 4 or, more rarely, 6 mm) are used to reduce fat, but they can be too large and unacceptable for all patients, especially for people with minimal or moderate fat deposits. Executing the procedure by blunt-ended cannulas with a small lumen can help emphasize the border of the lower jaw or perform a dissection throughout the neck in patients with minimal deformities of the subcutaneous layer. Liposuction distal to the area of primary interest should be aimed at smoothing the newly created contours. It is best to perform cannulas of smaller diameter, having one or two holes.

After completion of the preliminary tunneling, the cannula joins the suction. Fat is removed by directing the cannula through the tunneled region along the same radially divergent directions. Relatively atraumatic system of tunnels preserves continuity of vascular, nervous and lymphatic systems in the skin and deeper subcutaneous tissues. The surface direction of the tunnels is preserved by pulling the skin from the subcutaneous tissue with the end of the cannula. This is done with the left hand (surgeon-right-hander). It is used to guide the cannula, aspirate the fat into its lumen and maintain the correct working plane. The right arm is the engine that moves the cannula through the tissue. The correct level of stratification and uniform removal of fat are provided by uniform fan-shaped movements of the cannula. Extraction of fat in the plane above the subcutaneous muscle of the neck continues until the desired result is achieved. After removal of the main fat accumulation with smaller and less aggressive cannulas, the contours are smoothed. For these purposes, there are many different cannulas; authors prefer a cannula with a diameter of 2 mm with an end in the form of a spatula and one or two apertures.

Contouring the border of the lower jaw may require two additional incisions, behind each earlobe, hidden in the BTE folds. These incisions should be vertical and of the same length to allow the cannula to be 2 mm or 3 mm in diameter. The creation of a plane of subcutaneous dissection also begins with the help of small scissors, lifting the skin.

Cannula with a diameter of 2 and 3 mm can have one, two or three suction holes. Several holes make the liposuction more aggressive and can be used in the initial stage, to remove more fat. Smoothing cannulas with one or two holes will create a better postoperative contour.

Lateral zaushny access, in addition to podpobo-rodnomu, allows you to better approach the area around the corner of the lower jaw. Access through several incisions creates a large overlapping network of subcutaneous tunnels, which contributes to the maximum improvement of the contour. When moving the cannula in the subcutaneous plane, the technique of "arc and fan" is used. The opening of the cannula must not be directed upward, suction with this closed technique is in most cases performed only below the angle of the lower jaw, and the suction action must be stopped whenever the opening of the cannula is inserted or withdrawn from the incision. Some people believe that with large deposits of fat on the face, the surgeon can reasonably expand the area of liposuction over the lower jaw, using very small cannulas.

Frequent inspection of the suction area and the use of pinching and rolling techniques help the surgeon avoid removing excess fat. At the same time, the skin is gently grabbed between the thumb and forefinger and rolled between them. When the surgeon senses between the fingers a thin residual layer of fatty tissue, this indicates that enough fat has been removed. The extraction volume varies in different patients, but in most cases it ranges from 10 to 100 cm3.

Sometimes fat under the subcutaneous muscle of the neck contributes to the loss of the young contour of the cervico-chin angle. In such cases, the cannula can be guided more deeply through the sub-chin. When removing fat in this area, there is a small risk of damage to nerve structures, such as the marginal branch of the mandibular nerve, however, small vessels can be damaged. To prevent damage to laterally disposed nerve structures, the cannula dissection should be performed within the median line. Often after performing vigorous liposuction on the neck in patients who are subsequently tightened their face, an open examination of the middle line of the neck reveals a significant amount of fat that requires excision. The solution to this situation may be the use of a liposcope, but due to good blood supply, work here may require caution.

If a direct lyectomy is required in the midline area, additional fat can be excised under the control of the eye. Excision can be done with scissors or liposhever. For acute lylectomy, more precise excision and a slightly larger incision are required, which leads to damage to the vascular-neural bundles. Separation can be done with scissors for face lifting or Bovie coagulation suction at low power settings. When using electrocoagulation for this purpose, the skin is pulled upward and protected by the Converse retractor. Then, under the direct control of the eye, a plane of preparation is created.

Liposuction at fullness in the lower part of the buccal region as a primary operation should be carried out with extreme caution. Access to this area is through cuts in the BTE folds. If you do not need to process the entire area between the incision and the accumulation of fat, the suction force can not be applied until the cannula has been inserted into the desired accumulation of fat. Failure to do so may result in a significant failure between the incision and the created pocket in the adipose tissue.

When deciding on issues related to fat extraction in the jaw area, selection of patients is extremely important. In patients with excess and poor elasticity of the skin after the operation, which used to be fat, unattractive skin bags will remain. Even in properly selected individuals of a fairly young age, excessive fat removal can lead to apprehensions that will only age the face, creating the appearance of age-related fat atrophy.

Isolated liposuction in the middle part of the face can have catastrophic consequences if excess fat removal is performed, creating a noticeable withering and unevenness that is difficult to correct. It may be successful to economically suction off complete nasolabial elevations with small cannulas through intranasal access.

Before completing the procedure, it is necessary to evaluate the contour of the neck surface. The presence of pits usually means the preservation of residual bonds between subcutaneous fat and skin. Their separation usually solves this problem. Even small cords of the subcutaneous muscle of the neck can become more noticeable after liposuction. To prevent this in the postoperative period, the strands can be sewn through a sub-chin, with or without direct excision. If their manifestation is predictable, to prevent an even more pronounced contouring, liposuction should be moderate. To suture the divergent subcutaneous muscles, it may be necessary to extend the sub-chin. It must be performed with a smooth bend sideways, so that the incision does not move upward, on the lower jaw, when healing.

After the liposuction is completed and the final evaluation (by grasping the skin folds and rolling them between the fingers) has confirmed a good symmetry, the incisions are layer-by-layer closed with 6-0 threads and then strengthened with a patch. In order not to leave accumulations of blood and free fat balls, the contents of the pockets left after dissection are expressed. To prevent postoperative irritation in patients who have been removed large amounts of fat, skin is washed before rinsing the skin, removing most of the free or liquefied fat. Closed liposuction, performed as a basic procedure, does not require active drainage, but to reduce the edema of tissues and to fix the skin to the reconstituted surface, it is necessary to superimpose a light pressure bandage. If an open lipectomy was performed, more pressure is needed. The skin above the dissection area is first covered with soft cotton wool or Tefla (Kendall Company, USA), and then with a Kerlix-type net (Johnson and Johnson, USA). The area is finally closed with either an elastic bandage Coban (ZM Healthcare, USA), or a sling dressing. The elastic bandage can be moved, it is convenient and allows easy access to the operation area. The patient is instructed to limit head and neck movements for 36-48 hours in order to keep the skin tightly attached to the underlying soft tissue bed.

Liposuction as an additional procedure

The selection of suitable candidates for liposuction may also imply its use as an additional or improving procedure against the background of another primary operation. Although the purpose of the patient's visit to the doctor may be a discussion of liposuction, the surgeon may need to explain why the best way to rejuvenate the face is, for example, an increase in the chin, rhytidectomy or the plastic of the hypodermic neck muscle. Appropriate examination of the patient is extremely important for achieving the optimal surgical result, and the skills of its implementation should be improved at each visit.

• Liposuction combined with an increase in the chin

When sub-chiropractic lipomatosis is accompanied by microgenia and whether retrognatia, the results of only the chin increase, only correction of orthognathy, or only liposuction under the chin are less than satisfactory. With a combination of these approaches, the result can be striking. An additional task may be to restore the acute cervical-chin angle. Patients with a chamfered chin or low anterior hyoid bone will benefit from removal of the sub-chicken fat and increased chin protrusion.

Placing the incisions for combined liposuction under the chin and increasing the chin is similar to that for isolated liposuction, with one difference. If the chin is increased from the external access, the sub-chin is slightly extended in order to fit the size of the implant. According to the surgeon's preference, the implant can be inserted through oral access, a separate incision is made through the gum and lip. In this case, the chin and podbodborochnoe operating spaces should not be contacted. Penetration of saliva into the neck is undesirable. The chin implants that are installed intraorally tend to move upward, while those mounted outside are prone to bias downward, which creates a deformation called the witch's chin. The implant is held in place by fixing the seams and creating a pocket of the appropriate size.

• Liposuction as a complement to rhytidectomy

Liposuction by eliminating unwanted fat not only in the sub-chin, but also in the tragus and cheek, can significantly improve the results of rhytidectomy. The advantage of combining these techniques lies in the possibility of reconstructing the contour with a low risk of damage to the underlying vascular-neural structures. Before the introduction of liposuction into practice, the removal of fat from the area of the cheek was either not done at all, or was considered unfavorable because of the danger of nerve damage or uneven contour, due to too aggressive aspiration or traction. Access to the area of the cheeks from the standard section for facelift is difficult, and the idea of additional cuts would contradict the technique of well hidden incisions, worked out for the braces.

In order to fully appreciate the advantages of liposuction in facelift, three key points should be considered. First, closed liposuction is used to reduce visible fat deposits on the face with minimal bleeding. Secondly, the cannula, with the use of suction or without it, facilitates the allocation of the flap during a tightening. Finally, open liposuction completely restores the contour under direct visual control.

To remove noticeable accumulations of fat in the sub-chin, submandibular and lower cheek areas, first of all the standard technique of closed liposuction is used. The length of the incision under the chin is 5-8 mm; The initial preparation is done with small scissors. First, a cannula with a diameter of 3 or 4 mm can be used; Preliminary tunneling is useful, but not necessary. Further access to facial fat deposits is possible through cuts behind the ears and under the lobes of the ears, and excess skin will be eliminated during subsequent rhytidectomy. Despite this, nevertheless, an economical approach is recommended to remove fat in the middle part of the face and cheek area. Excessive aggressiveness with liposuction in this area can lead to unwanted contour unevenness.

After eliminating the excess fat around the neck and at the bottom of the face with liposuction, the allocation of facial flaps is completed by a standard way - scissors. Separation of the flaps after using the blunt cannula occurs usually quickly and easily. Subcutaneous bridges formed during tunneling are easily identified, crossed, and the allocation of the flap is completed. Relative atraumaticity of the process of blunt preparation allows to separate the flap to the nasolabial fold without damaging the vascular-neural formations.

After the allocation of the flap is complete, the plication is performed, the overlapping of the SMAS or the tightening in the deep plane (depending on the choice of the surgeon). For final refinement, liposuction can be used again. Usually, a blunt cannula with a diameter of 4 or 6 mm is chosen, and all areas where completeness or unevenness of the relief are marked are treated. The tip in the form of a spatula ensures maximum contact between the cannula and the soft tissue bed, required for tightness when sucked in open space. Unwanted fat accumulations are removed by applying the cannula opening directly to the subcutaneous bed and quickly moving it back and forth through the open surface of the created pocket. To ensure a reduction in completeness in the area where the majority of SMAS is held in the sutures in the early postoperative period, liposuction can be used prior to plication or lapping in front of the goat and ear. After the final evaluation, the final stage of rhytidectomy, including the excision of the skin, is performed in the usual way to identify the need for additional liposuction. After isolating the skin flaps that are usual for the facelift, access to the fatty body of the cheek is also facilitated; under them, directly into the buccal fat, under the visual control can be introduced a very small (1 or 2 mm in diameter) cannula.

[1], [2], [3], [4], [5]