Liposuction technique on the face and neck

The goal of liposuction, regardless of the technique, is to restore contour in areas of fat deposits by targeted reduction of localized fat accumulations, while minimizing external irregularities and scarring. The liposuction technique appears relatively simple and easy to use. However, to achieve optimal results, create smooth contours and reduce the likelihood of any postoperative problems, it is necessary to take into account some details.

The key is a careful, uniform reduction of fat in the neck and face. These areas are not easily concealed, so it is important to create the greatest possible symmetry of contour. Underestimating the amount of fat that must be removed to achieve aesthetic results may be a lesser evil than overly aggressive fat removal, which creates unnatural depressions or voids. Removing too much fat may expose the platysma bands, which in turn requires open platysmaplasty, alone or with a facelift, to correct the condition. For example, overly aggressive liposuction in the cervicomental area in a woman who has undergone a rhytidectomy may create a masculine appearance due to skeletonization of the thyroid notch. Contouring the notch creates the "pseudoglottic protrusion" characteristic of the male neck.

Liposuction of the face and neck can be performed using open and closed techniques. If the optimal aesthetic result for the patient can be achieved by combining liposuction with a facelift, a combination of open and closed techniques may be the right choice.

Liposuction as a primary operation

Incisions in the submental fold, in the fold behind the earlobe or in the vestibule of the nose are well camouflaged and provide excellent access to all areas of the face and neck. If an ultrasound-assisted liposuction system is used, longer incisions will be required to insert larger diameter cannulas and skin protection devices. An incision that is too small, regardless of the technique, may predispose to friction burns or to damage to the skin due to the reciprocating movements of the suction cannula. Incisions are usually 4 to 8 mm long. The incision should be able to pass a cannula with a diameter of 4-6 ml (i.e. the largest diameters suitable for liposuction of the face and neck).

After the incision is made, the skin immediately surrounding it is undercut with small tenotomy scissors to position the cannula in the correct plane and to prevent postoperative irregularities in the incision area. The correct plane of operative action is located just below the dermal-subdermal border. Preliminary tunneling (passing the cannula through the area of interest without turning on the suction) is often performed before active aspiration is started. In conditions of severe fibrosis of the neck tissues or after previous operations, the correct plane is difficult to determine, and tunneling allows the correct depth of dissection to be determined. After the start of the dissection, the cannula is inserted through the incision. To reduce tissue trauma around the incision, the suction should be temporarily turned off each time the cannula is withdrawn or inserted into the incision. This should be monitored by an assistant or scrub nurse, allowing the surgeon to concentrate on his task. Trauma at the access site can be prevented simply by clamping and releasing the suction tube.

The cannula is inserted through the incision in the direction of the wound channel itself, i.e. in the direction of the subcutaneous tissues and away from the dermis. When performing liposuction in the face and neck area, there are practically no indications for directing the cannula lumen openings toward 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 and significant irregularities in the postoperative period.

Lipoextraction begins by pre-tunneling the lipodystrophy area with a single-lumen cannula of 2, 3 or 4 mm diameter with a spatula-shaped end. These cannulas are the "workhorses" of neck liposuction. When treating submental lipomatosis, the dissection is done in a fan-shaped pattern across the neck, from one corner of the mandible to the other. The tunnels describe an arch that extends to the sternocleidomastoid muscles laterally and to the thyroid cartilage downwards. The starting point of the diverging tunnels is the incision site in the submental fold. The most intensive suction should be performed in the area of greatest fat deposition, which is marked with preoperative markings. Larger cannulas (3, 4, or, less commonly, 6 mm in diameter) are then used to reduce the fat volume, but these may be too large and inappropriate for all patients, particularly those with minimal to moderate fat deposits. Performing the procedure with blunt, small-lumen cannulas may help to accentuate the mandibular border or to dissect the entire neck in patients with minimal subcutaneous distortion. Liposuction distal to the area of primary interest should aim to smooth out the newly created contours and is best performed with smaller diameter, single- or dual-bore cannulas.

After the preliminary tunneling is completed, the cannula is attached to the suction. The fat is removed by guiding the cannula through the tunneled area in the same radially diverging directions. The relatively atraumatic tunnel system preserves the continuity of the vascular, nervous and lymphatic systems in the skin and deeper subcutaneous tissues. The superficial direction of the tunnels is maintained by pulling the skin away from the subcutaneous tissues with the end of the cannula. This is done with the left hand (of a right-handed surgeon). It is used to guide the cannula, aspirate the fat into its lumen and maintain the correct plane of work. The right hand is the motor, advancing the cannula through the tissue. The correct level of separation and uniform removal of fat are ensured by uniform fan-shaped movements of the cannula. Fat extraction in the plane above the platysma muscle is continued until the desired result is achieved. After removal of the main fat accumulation, contour smoothing is performed with smaller and less aggressive cannulas. A variety of cannulas are available for this purpose; The authors prefer a 2 mm diameter cannula with a spatula-shaped end and one or two holes.

Contouring the border of the mandible may require two additional incisions, behind each earlobe, hidden in the postauricular folds. These incisions should be vertical and long enough to allow passage of a 2- or 3-mm cannula. Creation of the subcutaneous dissection plane is also initiated with small scissors, elevating the skin.

The 2mm and 3mm cannula can have one, two or three suction holes. Multiple holes make liposuction more aggressive and can be used in the initial stage to remove more fat. Smoothing with a single or dual hole cannula will create a better post-operative contour.

The lateral postauricular approach, in addition to the submental approach, allows better access to the area behind the angle of the mandible. The multiple incision approach creates a large overlapping network of subcutaneous tunnels that allows for maximum contour improvement. The cannula is advanced in the subcutaneous plane using the "bow and fan" technique. The cannula opening should not be directed upward, suction in this closed technique is generally applied only below the angle of the mandible, and suction should be stopped whenever the cannula opening is inserted or withdrawn from the incision. Some believe that with large facial fat deposits, the surgeon may reasonably extend the liposuction area above the mandible using very small cannulas.

Frequent inspection of the suction area and the use of a pinching and rolling technique help the surgeon avoid removing excess fat. This involves gently grasping the skin between the thumb and forefinger and rolling it between them. When the surgeon feels a thin residual layer of fat between the fingers, this indicates that sufficient fat has been removed. The volume of extraction varies among patients, but in most cases it is between 10 and 100 cc.

Sometimes subplatysmal fat contributes to the loss of the youthful contour of the cervicomental angle. In such cases, the cannula can be directed deeper through a submental incision. When removing fat in this area, there is a small risk of damaging neural structures such as the marginal branch of the mandibular nerve, but it is possible to damage small vessels. To avoid damaging laterally located neural structures, the cannula dissection should be performed within the midline. Often, after vigorous liposuction of the neck in patients who will subsequently undergo a facelift, a significant amount of fat in the midline of the neck is found on open examination that requires excision. The use of a liposhaver may be a solution to this situation, but due to the good blood supply, caution may be required in this area.

If direct lipectomy is required in the midline area, additional fat can be excised under direct visualization. Excision can be performed with scissors or a liposhaver. Acute lipectomy requires more precise separation and a somewhat larger incision, which results in damage to the neurovascular bundles. Separation can be performed with facelift scissors or a Bovie coagulation suction at low power settings. When using electrocoagulation for this purpose, the skin is retracted upward and secured with a Converse retractor. The dissection plane is then created under direct visualization.

Liposuction of the lower cheek fat as a primary operation should be performed with extreme caution. Access to this area is through incisions in the folds behind the ears. Unless the entire area between the incision and the fat pad needs to be treated, suction should not be applied until the cannula has been inserted into the desired fat pad. Failure to do so may result in a significant gap between the incision and the created pocket in the fat pad.

When considering jaw fat extraction, patient selection is extremely important. Patients with excess and poorly elastic skin will be left with unattractive skin bags where fat used to be. Even in properly selected, fairly young individuals, excessive fat removal can result in depressions that will only age the face, creating the appearance of age-related fat atrophy.

Isolated liposuction of the midface can be disastrous if excessive fat removal is performed, creating noticeable depressions and irregularities that are difficult to correct. Sparing suctioning of the entire nasolabial eminences with small cannulas through an intranasal approach can be successful.

Before completing the procedure, it is necessary to evaluate the contour of the neck surface. The presence of dimples usually means that residual connections between the subcutaneous fat and the skin remain. Their separation usually solves this problem. Even small bands of the platysma muscle of the neck may become more visible after liposuction. To prevent this, the bands can be sutured postoperatively through a submental incision, with or without direct excision. If their appearance is predictable, liposuction should be moderate to prevent even more obvious contouring. To suture the diverged platysma muscles, it may be necessary to extend the submental incision. It should be performed with a smooth lateral bend, so that the incision does not shift upwards, onto the lower jaw, during healing.

After liposuction is completed and final assessment (by grasping the skin folds and rolling them between the fingers) has confirmed good symmetry, the incisions are closed in layers with 6-0 sutures and then secured with tape. To avoid accumulations of blood and free fat globules, the contents of the pockets remaining after dissection are expressed. To prevent postoperative irritation in patients who have had a large amount of fat removed, the cavity is irrigated before skin suturing, removing most of the free or liquefied fat. Closed liposuction performed as a primary procedure does not require active drainage, but a light pressure bandage should be applied to reduce tissue edema and to fix the skin to the recreated surface. If open lipectomy was also performed, greater pressure should be applied. The skin over the dissection area is first covered with soft cotton wool or Tefla (Kendall Company, USA) and then with a Kerlix mesh (Johnson and Johnson, USA). The area is permanently covered with either a Coban elastic bandage (3M Healthcare, USA) or a sling bandage. The elastic bandage can be moved, is comfortable, and allows easy access to the surgical area. The patient is instructed to limit head and neck movements for 36-48 hours to ensure that the skin adheres tightly to the underlying soft tissue bed.

Liposuction as an additional procedure

Selecting appropriate candidates for liposuction may also involve its use as an adjunct or enhancement procedure to another primary procedure. Although the purpose of a patient's visit to the doctor may be to discuss liposuction, the surgeon may need to explain why a better route to facial rejuvenation is, for example, a chin augmentation, rhytidectomy, or platysmaplasty. Proper patient assessment is critical to achieving an optimal surgical outcome, and skills in performing this should be refined at each visit.

• Liposuction combined with chin augmentation

When submental lipomatosis is accompanied by micrognathia or retrognathia, the results of chin augmentation alone, orthognathia correction alone, or submental liposuction alone are less than satisfactory. When these approaches are combined, the results can be dramatic. An additional goal may be to restore the acute cervicomental angle. Patients with a receding chin or a low anterior hyoid bone will benefit from submental fat removal and increased chin prominence.

The placement of incisions for combined submental liposuction and chin augmentation is similar to that for isolated liposuction, with one difference. If the chin is being augmented via an external approach, the submental incision is extended slightly to accommodate the size of the implant. At the surgeon’s discretion, the implant may be inserted via an oral approach, with a separate incision made through the gum and lip. In this case, the submental and submental surgical spaces should not come into contact. Penetration of saliva into the neck area is undesirable. Intraorally placed chin implants tend to migrate upward, while externally placed implants tend to migrate downward, creating a deformity called witch’s chin. Suture fixation and creation of an appropriately sized pocket help to hold the implant in place.

• Liposuction as a complement to rhytidectomy

Liposuction by removing unwanted fat not only from the submental area but also from the tragus and cheek can significantly improve the results of rhytidectomy. The advantage of combining these techniques is the ability to recreate the contour with a low risk of damaging the underlying vascular-nerve structures. Before the introduction of liposuction into practice, fat removal from the cheek area was either not performed at all or was considered unfavorable due to the risk of nerve damage or uneven contour due to too aggressive suction or traction. Access to the cheek area from a standard facelift incision is difficult, and the idea of additional incisions would contradict the technique of well-hidden incisions developed for the lift.

To fully appreciate the benefits of liposuction in a facelift, three key points should be considered. First, closed liposuction is used to reduce visible facial fat deposits with minimal bleeding. Second, a cannula, with or without suction, facilitates flap extraction during the lift. Finally, open liposuction completely restores the contour under direct visual control.

For removal of prominent fat deposits in the submental, submandibular, and lower cheek areas, the standard closed liposuction technique is used first. The submental incision is 5-8 mm long; initial dissection is performed with small scissors. A 3- or 4-mm cannula may be used initially; preliminary tunneling is helpful but not necessary. Further access to facial fat deposits is possible through incisions behind the ears and under the earlobes, and excess skin will be removed during a subsequent rhytidectomy. Nevertheless, a sparing approach to fat removal in the midface and cheek area is still recommended. Excessive aggressiveness in liposuction in this area may result in undesirable contour irregularities.

After removing excess fat from the neck and lower face using liposuction, the facial flaps are separated in the standard way - using scissors. Separation of the flaps after using a blunt cannula is usually quick and easy. The subcutaneous bridges formed during tunneling are easily identified, crossed, and the flap separation is complete. The relative atraumatic nature of the blunt dissection process allows the flap to be separated to the nasolabial fold without damaging the vascular-nerve structures.

Once the flap is complete, plication, SMAS overlap suturing, or deep plane lifting is performed (depending on the surgeon's choice). Liposuction may be used again for final finishing. A blunt cannula of 4 or 6 mm diameter is usually selected and all areas of fullness or irregularity are treated. The spatula-shaped tip ensures maximum contact between the cannula and the soft tissue bed, which is required for a seal when suctioning in an open space. Unwanted fat deposits are removed by applying the orifice of the cannula directly to the subcutaneous bed and rapidly moving it back and forth across the open surface of the created pocket. Liposuction may be used before plication or overlap in front of the tragus and ear to ensure fullness reduction in an area where much of the SMAS is held in place by sutures in the early postoperative period. After a final assessment to determine whether additional liposuction is needed, the final stage of the rhytidectomy, including skin excision, is performed in the usual manner. After the usual facelift skin flaps have been isolated, access to the buccal fat pad is also facilitated; a very small (1 or 2 mm in diameter) cannula can be inserted under them directly into the buccal fat under visual control.

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