Fig. 24.11 Microcannulas are used for closed liposuction. (a, b) The three access sites are strategically located under each ear lobe and under the chin. (c) Flat spatulated cannula for open neck liposuction. (Left)

7 mm. (Middle) 3 mm. (Right) 2 mm

7mm Flat spatulated cannula for open neck liposuction

c

3mm 2mm

A smooth surface is developed by suctioning an area from multiple directions in multiple planes. After each pass of the cannula it is directed in a new location. Multiple passes in the same plane will cause irregularities that may not be correctable. The uniformity of the skin surface can be checked visually, and also by feel as one runs ones fingers over the area of interest. Thickness is determined by pinching the skin and subcutaneous layer with the fingers of both hands and comparing one area to another. Another technique is to lift the skin and subcutaneous tissue with the microcannula. Lumpiness will be seen along the length of the cannula if one has not evenly removed fat from this area. The goal is to leave about 5 mm of fat. If fat is removed to the point where the dermis is in contact with the platysma, scarring and retraction are possible long-term sequelae. This is a problem that is not immediately obvious and is very difficult to repair.

Despite the fact that liposuction of subplatysmal fat has been described in the literature we feel that subplatysmal fat removal requires surgical approach through an open submental incision. Clearly, blind liposuction in this area could be hazardous. When suctioning above the mandible in the jowl region, it is important to avoid approaching this area from the submental access site as this will put the facial nerve at risk. In the jowl area, aggressive liposuction is also a reason for marginal mandibular nerve injury. When suctioning the jowl area very little fat needs to be removed and it is easy to

create a depression or asymmetry. One can consider using a 10 cc syringe for the source suction in this area and/or a cannula no bigger than 1.75 mm. Typically, only 4–10 ml of fat needs to be removed from each side. Precise measurement of the aspirated fat is easily achieved with this technique and it is more difficult to perform oversuction in the jowl as compared to using traditional aspiration device.

At the completion of the procedure the access sites are closed with a single 5/0 plain gut suture (Ethicon). Reston Foam® 15631 (3M Medical St. Paul Minnesota) is placed over the submental region (Fig. 24.12). It is important to ensure that the underlying skin is smoothly redraped in the neck area prior to dressing placement. Coban® Wrap (3M Medical-Surgical) is then wrapped around the submentum and head for 24 h. On postoperative day one the Coban is removed and a Hopping® neck lift bra is placed. This is worn 24 h each day for the first week and then only at night for the following 2 weeks.

24.8Summary of Critical Points for Successful Liposuction

1.Proper patient selection is essential.

2.Preoperative markings should be precise.

3.Infiltrate tumescent anesthesia in a uniform manner.

4.Avoid suctioning against the dermis (The cannula holes should be oriented toward the platysma.)

5.Place access sites for maximal cannula overlap and camouflage.

6.Use an appropriate amount of epinephrine in the neck. (The extensive blood supply of the face/neck results in a more rapid loss of vasoconstriction with a resultant bloodier aspirate and potentially an increased likelihood of bruising and seroma formation.)

7.Ensure that the fat is suctioned from multiple directions to decrease the likelihood of contour irregularities.

8.Beware of aggressive suctioning in the region of the marginal mandibular nerve. Consider syringe only suctioning in the region of jowling (4–10 cm3/ side) or, at least limit, the amount of suctioning in the jowl to avoid nerve injury or irregularities.

9.Leave a uniform layer of fat behind.

10.Avoid aggressive suctioning over the mandibular body. One should aggressively suction under this area in order to accentuate the mandibular shadow.

24.9Chin Implantation

Alloplastic chin implantation is a simple procedure with minimal risk, and is easily reversible. Correcting even mild deficiencies in the chin projection can dramatically improve the patient’s appearance. The lack of appropriate chin projection can be congenital or the result of the aging process as mandibular bone begins to resorb. Lack of projection may even be the result of both of these entities. As previously mentioned, the easiest technique to assess whether the patient has

adequate anterior projection is to superimpose a line that is perpendicular to the Frankfurt horizontal line. The superimposed line should touch the vermillion border of the lower lip. The chin should ideally just touch this line or be no more than 2 mm posterior to it in females. This technique can also be used to estimate the implant size required preoperatively. Estimates of implant size can be made at the time of surgery using sizers, but patient positioning and tissue distortion from tumescent anesthesia may make intraoperative sizing difficult. Because of this the size of the implant is routinely determined prior to surgery.

The implant is placed through a 1 cm long submental incision if the implant is being placed without neck surgery. The incision must be moved 2–3 mm posterior to the submental crease when augmenting the chin. If the incision is not moved posteriorly the anterior pull of the implant will tend to make the scar visible. Prior to surgery, we determine where the midline of the mentum is and mark it. The authors also outline where we expect the implant to be positioned. Following skin incision electrocautery is used to dissect down to the periosteum of the mandible in the midline. Next, a subperiosteal pocket is created at the lower border of the mandible to the right and left of midline. The pockets should be adequate in length to accommodate the implant while avoiding overdissection so as to not affect implant stability. Care is taken not to injure the mental nerves. This can be achieved by ensuring that the dissection does not extend more than 8 mm above the mandibular border. The periosteal elevator should hug the inferior border of the mandible in the subperiosteal plane to maintain proper position. An Aufricht retractor can be used to help place the implant (Fig. 24.13). The silicone implant is then secured to the fascia at the inferior border of the mandible with a 2–0 Vicryl suture. Prior to securing the