Methodological and physiological considerations regarding liposuction on the face and neck

There are many different techniques for achieving the main purpose of liposuction. The techniques used on the face and neck, although very similar in technique to those used on the body, should differ due to the peculiarities of the anatomy and physiology of these areas. When taking liposuction on the face and neck, the surgeon should remember about the smaller thickness of the facial skin, the proximity of the motor and sensory nerves (especially the branch of the mandible edge from the facial nerve system), the depth of the fat that requires aspiration, and the natural effect of aging on the fat deposits in the face area .

The technique of liposuction, introduced in the 70s of the last century, involves the use of a rigid cannula and an aspirator. Canyule quickly moves forward and back through the fat deposits in the subcutaneous tunnels. Fat cells are torn, tightening in a perforated cannula with negative pressure created by sucking. If the suction pressure is high enough, the fat cells are lysed and destroyed. The use of this technique provides stably good results.

The addition of hypotonic infiltration (the introduction of a hypotonic saline solution with a local anesthetic) into the technique of liposuction has found wide application in the reconstruction of the contours of the body. This allows you to perform liposuction on a large stretch under the intravenous sedation, and infiltration of physiological saline facilitates the rupture of cell membranes and facilitates the aspiration of a large volume of fat. Hypotonic infiltration involves the introduction of a vasoconstrictive solution into the entire bed for liposuction. Waiting for 15 minutes before the start of the procedure allows adrenaline to act and significantly reduces bleeding. Some surgeons use hypotonic infiltration in facial plastic not only for aspiration, but, in smaller volumes, and for tissue dissection. Hypotonic infiltration can be harmful in small areas, such as face and neck, due to the distortion caused by it. This can make symmetrical fat removal difficult. For a body involving large volume surgery, the benefits of hypotonic infiltration are to facilitate the removal of fat and the dissipation of heat released, especially when using ultrasound energy. The main disadvantage of using a hypotonic solution is the problem of moving the fluid into a third space.

The need for liposuction on the body and the ongoing search for ways to improve results with a minimum of complications led to the development of another, relatively new technique. It involves the treatment of fat tissue by ultrasound from the inside or outside, which leads to rupture of fat cells and facilitating aspiration. Although ultrasound for tissue aspiration has been used since the late 60s of the last century, it was only recently adapted for liposuction purposes. Many of the most frequent areas of body fat deposition have high fiber content, and the advancement of the liposuction cannula with an internal or external ultrasound device not only requires less effort, but is much more effective in fat aspiration. Some studies of liposuction using ultrasound on the body also speak of less edema and signs of tissue injury after surgery.

Physiologically, the energy of ultrasound is converted into mechanical vibrations, which create a "micromechanical effect - the effect of cavitation (cycles of expansion and contraction of fatty tissue elements), which leads to explosion, cell destruction, that is, fat liquefaction and temperature effects on fat cells." Numerous studies have identified such problems associated with subcutaneous use of ultrasound energy, such as the formation of excess heat at the site of the cutaneous incision, as well as the resulting complications in the remote areas of the subcutaneous space. In modern literature, the use of external ultrasonic devices for liposuction is discussed less often. It is noted that such devices have similar advantages, simplifying surgical intervention and shortening the postoperative period, but still require serious research. The latest publications devoted to this technique do not contain information on the methods of using external devices, but discuss the safety of their use. Plastic surgeons should be careful when considering the possibility of using internal ultrasound-enhanced liposuction on the face and neck due to the proximity of nerve structures, both sensitive and motor, as well as a smaller thickness of the dermis and epidermis. In animal studies, the effect of ultrasound energy on nerve tissue was evaluated. Their results showed that low-amplitude ultrasonic energy, applied directly to the nerve, causes its visible damage. However, no functional impairment of nerve conduction occurs until the ultrasound amplitude increases. Most sources of ultrasound-enhanced liposuction recommend that manufacturers follow the manufacturer's recommendations for power settings and consider these settings to be safe enough. When searching the Medline system, we did not find controlled studies proving safety or demonstrating the additional benefits of liposuction on the face and neck, enhanced by ultrasound, compared with the standard procedure for mechanical liposuction of microcannons.

The latest achievement of liposuction is a liposcope, recommended by Gross and Becker for direct lipectomy or for closed lipectomy in the face and neck area. A similar device made it possible to make a significant step in endoscopic sinus surgery; some experts also recommend it for use with the plastic back of the nose. Liposheaver is a protected, mechanized blade that cuts off fat either under direct observation or in the subcutaneous space. It is reported that the traumatic nature of this procedure is lower than with the standard technique, since fat does not come off, but is cut off. However, it is interesting that with liposuction, in the original version of Schudde, an acute curette-type instrument was used, which cut off, rather than tore off fat. This technique fell into disgrace after reports of tissue death and even loss of limbs due to vascular damage.

Cutting fat differs from traditional techniques, the technique of hypotonic infiltration and ultrasonic liposuction in that it does not require high vacuum during suction, actively excising, and not tearing off fatty deposits. This method, although it has a principle similar to acute curettage, differs from it in that the network of tunnels created by the lipouchever cannula is very similar to that of traditional methods. Its creation preserves vascular-neural formations. Comparative multicentre studies have demonstrated the successful use of this device and offered it simply as an alternative to traditional liposuction, possibly with less trauma and more complete lipolysis, in experienced hands. When using this device, you need to be sure that there is excision and suction of only subcutaneous fat, without contact with the dermis. With a closed procedure, the uniform removal of fat and the preservation of blood vessels and nerves is provided by contouring the cannula and by the fact that the surgeon pulls the skin upwards with a non-dominant hand. Compared with the traditional method of liposuction, the use of a liposcope can be accompanied by a slight increase in the frequency of development of serum and hematoma.

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