Suction lipectomy is an effective means of recontouring the face that has been popularized and refined over the past 30 years.¹^–⁵ As with all cosmetic surgery, understanding the anatomy, physiology, and changes that result from the aging process is imperative. On the basis of these changes, a logical approach to the integration of suction-assisted lipocontouring into the practice of facial plastic and reconstructive surgery is possible (Fig. 31-1).

Figure 31-1. The integration of liposuctioning into facial plastic and reconstructive surgery.

The distribution of body fat is a consequence of genetics and is influenced by hormones, diet, exercise, medications, and patient age. It has become apparent through tissue culture studies that, after a critical mass within an adipocyte has been reached, hyperplasia can occur.⁶ Although the mechanism of adipocyte hyperplasia has not yet been determined, the consensus remains that any significant change in fat deposition occurs through the enlargement rather than the addition of cells.⁷ Diet-resistant localized fat deposits, which are ideal for lipocontouring, may represent localized adipocyte hyperplasia. Liposuction reduces the number of adipocytes regardless of their size and therefore should yield a lasting result, unless excessive weight gain occurs. The liposuctioned regions of hypertrophy should respond to weight gain in a fashion that is similar to adipocytes in other regions of the body and, therefore, should be resistant to significant contour changes that are out of proportion with overall weight fluctuation.

Liposuction involves the application of negative pressure through a hollow cannula with a 3- to 6-mm lumen in the subcutaneous plane. Fat is then avulsed as atraumatically as possible. Because of the loose intercellular connections, fat cells are more easily aspirated than tissues with greater structural integrity (e.g., muscle, vessels, nerves). The standard suction cannula has no cutting surface; therefore structures with more integrity are protected.

Liposhaving has recently been advocated as an alternative to liposuction. In this technique, a soft tissue shaver is used with minimal suction to gently shave adipocytes.² The safety of this technique is of concern, and further investigation is under way. With liposuction and liposhaving, preserving important structures and maintaining bridges of uninterrupted tissue between the deep and superficial layers in an effort to maintain a healthier skin flap are the principles to be followed. Ultrasonic liposuction adds the mechanical agitation of the cannula to assist in the dissection and release of adipocytes and is usually done in conjunction with tumescent infiltration.⁸ Recently the use of ultrasonography has been used both internally and externally to assist with liposuction. The ultrasonic energy is transferred into mechanical vibrations that cause the microcavities in the adipocytes to implode, thereby resulting in the liquefaction of the fat.⁹ Multiple studies have shown potential complications with the use of subcutaneous ultrasonic energy resulting from heat generated at the cutaneous incision site and the more distal subdermal sites.⁸^–¹⁰ To date there are no controlled studies that demonstrate any added benefit from ultrasonic-assisted liposuction in the face and neck as compared with the standard technique.

Patient Selection

One of the greatest challenges with facial plastic surgery is the art of proper patient selection, and lipocontouring is no exception. Patient selection begins with an informal interview to get a sense of the patient’s motivation, expectation, and cooperation. The patient’s motivation for pursuing a cosmetic procedure should be investigated. Some patients expect a change in external appearance to have a significant impact on their personal or professional lives (e.g., to get a promotion at work, to dissuade a spouse’s infidelity); these patients are bound to be disappointed. A patient’s expectations should be precise and realistic. Lipocontouring allows for the removal of a particular area of subcutaneous fullness; although it will not have a direct impact on other areas, the change in contour may create the illusion of affecting surrounding areas and thereby influence the overall balance of the face. For example, a submental lipectomy may appear to enhance chin projection (Fig. 31-2), shorten the vertical height of the face, and create a wider and more cherubic-appearing face. Likewise, facial and jaw lipocontouring may create a more angular facial contour (Fig. 31-3) but will not increase malar projection and could create a wasted appearance. The patient’s expectations should be communicated preoperatively. Computer imaging can aid in communication, but it can also be misleading if not used prudently. Cooperation is imperative during the postoperative phase. A patient who cannot avoid the sun or continue with a pressure dressing postoperatively is a poor candidate for lipocontouring and should be dissuaded from pursuing surgery.

Figure 31-2. Preoperative (A) and postoperative (B) photographs show the illusion of enhanced chin projection after submental and submandibular liposuction, as well as the enhancement of the mandibular margin with improvement of the cervicomental angle.

Figure 31-3. Preoperative (A) and postoperative (B) photographs show elimination of the double chin and augmentation of the facial skeleton status after jowl, submental, and submandibular liposuction.

The ideal patient is not particularly overweight and has a localized fullness that is the result of an isolated pocket of subcutaneous adipose tissue refractory to weight loss. A patient who reports a familial pattern or who has had a double chin since childhood is a good candidate. The submental, melolabial, submandibular, and buccal areas lend themselves well to lipocontouring. Younger patients tend to have greater skin elasticity, which contracts better on the new subcutaneous contour; these candidates are ideal for isolated lipocontouring. Conversely, the loss of skin elasticity and turgor in older patients will necessitate a skin-tightening procedure (see Fig. 31-17). Obese patients have excess adipose tissue in multiple layers and do not respond well to lipocontouring. Moreover, this procedure is not intended to replace general weight control.

Common Pitfalls

Patient evaluation may yield common pitfalls that lead to untoward effects:

1. Significant ptosis of facial skin may appear accentuated after lipocontouring, thereby creating a more aged appearance; these problems are best addressed with a formal face lift.⁹

2. Lipocontouring depends on the skin’s ability to contract and adhere to the new subcutaneous bed, and several factors may interfere with this intrinsic property of the skin (e.g., age, radiation, scarring, actinic injury, smoking).

3. Skeletal insufficiency may reduce structural definition and give the illusion of excess fullness of a certain area (e.g., the retrusive chin and low hyoid bone causing the blunted cervicomental angle); ancillary chin implantation or genioplasty may significantly improve the aesthetic contour (Fig. 31-4).

4. Muscular problems (e.g., platysmal lift, platysmal plication, imbrication) may be present.

5. Ptotic submandibular glands and hypertrophy of parotid glands can mimic areas of excess adipose collection and should be appreciated and not traumatized.

Figure 31-4. Preoperative (A) and postoperative (B) photographs show chin augmentation in conjunction with cervical liposuction.

Instrumentation

The instrumentation for lipocontouring the face and neck remains uncomplicated: a vacuum generator with the capability of reaching 1 atmosphere of negative pressure, a disposable canister to function as a trap for the aspirated fat, sterile tubing, and relatively few liposuction cannulas. The cannulas are available from multiple manufacturers. Some surgeons prefer the round over the spatulated tip, and some prefer the cannulas in which the distal 1.5 to 2 cm is slightly angulated. Angulation of the distal portion allows the positioning of the aspiration port (on the deep surface away from the skin) to be determined on palpation. Cannulas that are 3 to 6 mm are most useful for liposuction. For liposuction. a soft tissue shaver is used (Fig. 31-5), such as the endoscopic soft tissue shaver or the cartilage shaver used in joint surgery. Cannula size varies from 2.9 to 4.8 mm for liposhaving.

Figure 31-5. Soft tissue shavers and cannulas of various sizes.

Technique

Patient Preparation

Preoperatively, the patient is given routine instructions, such as to take nothing by mouth after midnight, to avoid any medications that alter platelet function, and to avoid the consumption of alcohol. Patients are instructed to wash their face and hair with an antiseptic soap and to remove all makeup and hair-care products. Prescriptions for antibiotics and pain medicine are given to the patient preoperatively to fill before the surgical procedure. When the patient arrives for surgery, an intravenous line is started and preoperative antibiotics are administered. The patient is marked in the upright position, with the areas to be suctioned circumscribed and the zones of feathering indicated (Fig. 31-6). Anatomic landmarks (e.g., the angle of the mandible, the anterior border of the sternocleidomastoid muscle, the hyoid bone and thyroid notch) may also be marked (see Fig. 31-6). After marking has been completed, the patient is taken to the operative suite, where sedation and infiltration are carried out before preparing and draping the patient. This approach allows additional time for vasoconstriction to occur before surgery.

Figure 31-6. Preoperative marking of anatomic structures, including the margin of the mandible, the sternocleidomastoid muscle, and the hyoid bone, with stippling of lateral feathered regions and a vertical line through prominent submental fat pad.

Anesthesia

Cosmetic procedures (by themselves or in conjunction with other such procedures) are performed under intravenous sedation and infiltration anesthesia. Sedation is administered by an anesthetist with close monitoring of the patient, allowing for the virtually painless infiltration and nerve block. Submental and submandibular sculpturing are done with a block of the cervical plexus and mental nerve and with direct infiltration. Facial and melolabial contouring is accomplished with mental and infraorbital nerve block with infiltration. Block and infiltration are achieved using 0.5% lidocaine with 1 : 200,000 epinephrine. Long-acting agents are unnecessary for these patients.

Adequate sedation is paramount but generally needs to be heavy only during nerve block and infiltration of the local anesthetic. Midazolam, fentanyl, and propofol are short-acting agents and combine sedation with analgesia and amnesia. When necessary, these procedures are performed under general anesthesia. In this case, infiltration without nerve block is sufficient to obtain vasoconstriction and improve hemostasis.

Surgery

The location of incisions depends on the site to be contoured, and marking and infiltration are done accordingly. Incisions are limited to 5 to 10 mm and are made within relaxed skin tension lines. The submental region is usually done first, then the jaw and posterior cervical areas, followed by the region of the melolabial fold, as indicated. Flaps are then elevated, starting with a small cannula and graduating to the cannula size to be used for the lipectomy. A 5-mm cannula is usually used in the submandibular, submental, and jowl areas, and a 3-mm cannula is used for the melolabial fold.

A nonaspirative cannula is used to make multiple interconnecting tunnels throughout the region to be aspirated. During the nonaspirative phase of flap elevation, it is important to follow the same technique that would be followed when aspirating. The aspiration port should be kept on the deep surface. The skin incision is stabilized with countertraction using a skin hook, and the correct plane is identified with scissors (Fig. 31-7). Graduating cannula sizes are used to develop the tunneling after the cannula is in the correct plane (Fig. 31-8). The free hand is used to palpate the cannula tip and determine the depth of dissection (Fig. 31-9). Dissection is carried out in a spokelike fashion from the incision; multiple distal pseudopods from each spoke are used to ensure that lateral aspiration with feathering is executed thoroughly (Fig. 31-10). Additionally, nonaspiration tunneling is performed beyond the margins of the area to be aspirated to allow for complete redraping. The surgeon should concentrate on distal aspiration, because each repetitive motion (Fig. 31-11) of the cannula crosses over the proximal adipose tissue in the region adjacent to the original insertion, possibly resulting in a hollowed appearance at that point. Hollowing and inconsistent flap elevation can also be avoided by palpating the cannula tip and preserving some fat on the undersurface of the flap.

Figure 31-7. Identification of the plane of dissection using Metzenbaum scissors.

Figure 31-8. Use of the suction cannula to develop subcutaneous tunnels while stabilizing the skin with a skin hook.

Figure 31-9. Photographic (A) and diagrammatic (B) representations of the transcutaneous palpation of the distal cannula to ensure the depth of dissection and the location of the distal cannula lumen.

Figure 31-10. Distal feathering to ensure smooth transition to nonaspirated sites.

Figure 31-11. Multiple distal tunneling to ensure smooth transition in all regions and to avoid overreduction of the immediate submental adiposity.

After complete nonaspiration elevation has been accomplished, the suction is applied at one atmosphere of negative pressure, and multiple passes are re-executed. The assessment of evacuated fat may require the release of the vacuum so that any fat in the cannula and tube may be drawn into the canister; this approach may be necessary when the volume removed is small. Aspiration from the postauricular incision includes the jowl, posterior cervical, and submandibular regions (Fig. 31-12).

Figure 31-12. Suction lipectomy of the jowl, posterior cervical, and submandibular regions, which can be approached through the postauricular incision.

Cross-hatching occurs with the submandibular portions aspirated from the submental incision. In aspiration of the jowl, it is imperative to release suction when withdrawing the cannula over the posterior facial soft tissue and masseter because this area may not require aspiration, and a groove may be created in the posterior face. The margins can be tapered with a smaller cannula or with fewer passes. Liposuction of the melolabial fold or, more appropriately, of the superior border of the fold is performed with a small cannula through an incision in the nasal vestibule (Fig. 31-13).

Figure 31-13. Sites that can be approached through the submental, postauricular, and vestibular incisions.

Submental lipectomy should extend inferiorly to the level of the thyroid cartilage, posteriorly to the anterior border of the sternocleidomastoid muscle (with feathering over the muscle), and superiorly to the margin of the mandible. Lipectomy directed from the postauricular incision can extend anteriorly to the submandibular area to the anterior border of the platysma muscle and superiorly to the margin of the mandible. In the jowl, the specific deposit is aspirated, and feathering should be extended to the oral commissure and inferiorly to the margin of the mandible.

With liposhaving (Fig. 31-14), flap elevation is done in a similar fashion. The cannula is inserted with the blade inactive. After the blade is activated, extreme care should be taken at the incision to avoid damage to the skin margins. The cannula is passed in a more delicate fashion and at a slower rate than it is with liposuction, because shaving—rather than avulsion—is occurring. Minimal amounts of suction are applied, and the cannula must remain in motion when the blade is active, because it will shave progressively deeper, thereby jeopardizing other structures.