-------------------------------------------------------------------------------- TITLE: LIPOSUCTION AND LIPOAUGMENTATION OF THE HEAD AND NECK SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds DATE: March 23, 1994 RESIDENT PHYSICIAN: R. Paul Fulmer, MD FACULTY: Karen H. Calhoun, MD DATABASE ADMINISTRATOR: Melinda McCracken, M.S. -------------------------------------------------------------------------------- "This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion." I.History A. Passott in 1919 credited with first neck defatting procedure. B. Maliniak in 1932 first to describe in detail neck defatting procedures. C. Davis in 1955 referred to the removal of submental fat by curette. D. Adamson in 1964 reported a technique in which an elliptical portion of redundant neck skin was resected at the hyoid bone and underlying fat pads were completely resected through the same incision. E. Schrudde in 1922 promoted a technique he termed "Lipexeresis" wherein the fat tissue was scraped from its site by a uterine catheter. F. Fischer around the same time used a morselizing device that was combined with a power sprayer and an aspiration tube for the same purpose as Schrudde. G. Teimourian was one of the early U.S. pioneers who utilized curettes and fascia strippers. H. Grezer called his method "suction assisted lipectomy" and promoted it within the American Society of Plastic and Reconstructive Surgery. Developed many new canulas. I. Overall, suction lipectomy was first advocated and popularized by French surgeons for "riding breeches deformity" of the body. II. Applied Anatomy A. Superficial Muscular Aponeurotic Systems (SMAS): 1. A thin fascial layer lying beneath the skin and subcutaneous tissue of the lateral face. 2. This layer is in continuity with the posterior portion of the frontalis muscle in the upper face and with the platysma interiorly. Medially it passes through the melolabial fold and attaches directly to the nasolabial crease. B. Superficial Cervical Fascia: Thin layer investing the platysma and may contain significant amounts of adipose tissue. C. Deep Cervical Fascia: Lies deep to the platysma and invests the muscles of the neck. D. Platysma muscle: subcutaneous fan-like muscle: It covers the lower border of the mandible and the clavicle. The anterior medial border of the platysma may decussate in the midline below the chin and leave the anterior part of the neck uncovered,(submental platysmal dehiscence with fat herniation). The external jugular vein and greater auricular nerve are not covered by the platysma in the superior part of the posterior triangle and are vulnerable to surgical dissection in this area. E. Frontal branch of the facial nerve passes on a line from 0.5 cm inferior to the tragus to 1.5 cm above the lateral end of the eyebrow; beyond the zygomatic arch the nerve is found subcutaneously lying directly on the temporal fascia. F. Buccal branch of the facial nerve is below the SMAS anterior to the parotid; SMAS is very fragile in this region. Nerve is inferior to the imaginary line passing from the tragus to the alar base of the nose. G. Marginal branch of the facial nerve crosses the inferior border of the mandible posterior to the facial artery. As it passes the facial artery, it becomes superior to the inferior border of the mandible. At a distance of 1-2 cm from the lateral commissure, the nerve becomes superficial to the platysma. III. Adipocytes A. The number of adipocytes in human adipose tissue is fixed approximately 25 billion after puberty. B. The size of the cell may change by incorporating triglycerides. C. Metabolism of adipocytes is controlled by hormonal effects and food ingestion. These hormonal effects are both anabolic(ie. insulin) and catabolic in nature. D. Weight loss studies have revealed that fat cells have shrunk in size by up to 45%, but the number of cells appear to be relatively fixed. E. Cervicofacial fat distribution is strongly influenced by genetic factors, and stays relatively constant even with swings in total body weight. Therefore, if the patient controls their dietary intake and exercises regularly, then the plastic surgeon can consider surgical changes in the cervicofacial fat to be permanent. F. Diabetes, Cushing's syndrome, adrenogenital syndrome, and hyperinsulinism are examples of disease states which may affect the pattern of fat distribution. IV. Noncosmetic Applications of Liposuction A. lipomas B. multiple lipoma syndrome C. flap undermining D. defatting flaps - as described by Wooden, et al for revising microvascular free flaps once they adequately cover the defect, (@ least 3 months post tissue transfer). Likewise this can be used for defatting pedicled flaps such as "precise" midline forehead flaps, which we have done many times with Dr. Calhoun in the minor room. E. cervical fat pads or "buffalo humps" F. hypertrophic insulin lipodystrophy G. defatting obese patients prior to tracheostomy V. Basic Concepts and Principles A. Facial skin has a rich blood supply and lymphatic drainage. - Fat which is less than 1 cm thick derives its blood supply from the descending branches of the subdermal plexus. However is the fat is greater than 1 cm thick, then it depends largely on blood supply from the ascending fascial arteries. Therefore suctioning fat over fascia will produce more dramatic results in areas of thicker fat. B. Amount of fat in the face and neck is not great and stays relatively constant. C. With advancing age, the SMAS is transformed into an inelastic sheet and muscle tone is relaxed. Complete removal of excess fat, will cause excess skin to appear as though there are more wrinkles and therefore will require the creation of a skin flap which can be redraped at the end of the cervicofacial lipo-suction. D. Must follow basic principles to achieve satisfactory results with minimal morbidity. 1. Prevention of injury to the dermis - never directing the cannula aperture toward the skin surface as this can traumatize the dermis and result in pitting and fixation of the skin to the underlying fascia. 2. Thin(at least 2 mm) subdermal fat layer is preserved - This is necessary to maintain skin sensation, cutaneous lymphatic drainage, tonicity, and trophicity. 3. Prevention of injury to deep tissue and structures. E. Cell viability and metabolism following liposuction has been well documented. Minimal damage to the fat lobule has been seen after the passage of suction cannulas as long as the cannula was no smaller than 16-18 gauge. 20 gauge and smaller cannulas caused cell-to-cell disruption. F. Fat can be harvested using the similar technique and 1/2 atm of suction. The average time for graft stabilization has been documented to be between 6 to 9 months. Once stable, 75% to 80% of the original graft volume should remain. Liposuction remains the ideal technique for harvesting fat, because it produces small, uniform quantities of fat that maximize the surface area-to-volume ratio and thus facilitate oxygen diffusion in the graft. III.Purpose " The purpose of any liposurgical procedure is to improve the contour by either removing or replacing fat." VI. Equipment A. Cannulas (many types) 1. Rationale for selecting a particular cannula based on case of removal of fat, ability to dissect through the subcutaneous tissue and fat with minimal force, maximal cannula size to allow easy removal of fat, without producing noticeable ridges or waves. 2. Flat spatula tip a) creates a smaller tunnel with less tissue trauma and smoother scarring b) facilitates control and manipulation over thin, delicate cervicofacial skin and structures c) less resistance to tissue penetration d) less incidence of skin penetration 3. Round bullet type tip a) increased risk of tissue penetration b) more resistance to tissue penetration c) more suction curettage than with spatula 4. Flat tip a) useful for feathering edges, to allow a smooth transition b) inefficient fat removal due to shallow aperture lumen 5. Open basket tip a) tendency to curette through fat and tear the fibrous perpendicular connective tissue bands that hold the vascular network b) removal of fat more rapidly, but increased risk of bleeding c) excellent for lipoma or gynecomastia as they will shred the dense fibrous stroma present. B. Suction apparatus 1. Supplied by machine; generally 1/2 to 1 atmosphere is adequate 2. Some physicians, especially dermatologists advocate syringe assisted apparatus a) believe it to be less traumatic, and also more precise and accurate. b) less expensive start up costs. c) small amount of normal saline placed into syringe to act as a cushion and reportedly removes more fat at same place, sucks out less blood, less nerve trauma, and less trauma to fat during transportation avoiding vaporization which is better for lipoinjection. VII. Preop Evaluation A. Age B. Skin: elasticity, tone, redundancy C. Location of fat deposit D. Facial contour 1. three dimensional evaluation of abnormal fat deposition and its relationship with the facial skeleton. 2. mid-face and neck-chin angle are major areas 3. Ellenbogen states an aesthetically pleasing neck should have: a) distinct inferior submandibular border b) subhyoid depression c) thyroid cartilage bulge d) visible anterior SCM border e) cervico-mental angle between 105 and 120 degrees E. Platysma F. Does the patient need malarplasty, mentoplasty, or rhytidectomy? Can liposuction alone benefit? VIII. Operative Procedure: A. Skin marking must be done in an upright position to maximize the effect of gravity. B. Anesthesia: general or local with sedation. C. Incisions: usually just large enough to admit cannula and hidden in the facial line 1. submental and submandibular incisions are made in the submental crease below the mentum and below ear lobe. - Adamson describes removal of the preplatysmal fat in the submental region with liposuction followed by direct excision of the subplatysmal fat and then platysmal plication to rejuvenate the submental region. 2. glabella incision made in crease at root of nose: minimal fat is removed but it breaks up the fibrous attachments in this region and allows redrapping of the skin in this area. 3. jowl incision is made just inferior to the earlobe: when maneuvered over the mandible, always palpate the tip of the cannula and its proximity to the angle of the mandible and the corner of the mouth. May also reach this area from a submental incision. 4. melolabial mound incision made in nasal vestibule: fat removal is negligible: felt that the breaking up of the connective tissue fascia induces the depression of the cheek by subcutaneous scarring. Limit suction only to mound area, no dressing is required. Redundant medial cheek fat can also be removed in this manner with a 3mm cannula. 5. malar area or "sad pad" incision made in the crow's feet line at lateral orbit: this area cannot be corrected by conventional rhytidectomy. 6. buccal fat suction performed on the Caldwell-luc incision line of oral mucosa. This can also be removed using direct excision in the buccal sulcus. 7. pretragal incision utilized to helping elevate rhytidectomy flaps in temporal and malar area only., no suction, for 2-3 cm 8. posterior cervical incision made on outlined facelift incision near hairline over mastoid; helps to elevate rhytidectomy flaps over the SCM. IX. Techniques A. Closed (liposuction only) - a 2-7mm incision is made and then a pocket is created with scissors to allow the introduction of a liposuction cannula. The cannula is then inserted at a 90 degree angle to the skin with the open port down. The non-dominant hand pinches the tissue to be removed above the cannula. The area to suction is pretunneled WITHOUT SUCTION, followed by similar technique with the suction on at 1/2 to 1 atms. 1. Direct approach - involves an incision over the area to reduce and then liposuction directly into this area,(ie. submental liposuction). 2. Indirect approach - involves liposuctioning around an area which needs smoothing out and then redrapping the skin in hopes of improving the contour, (ie. bilateral incisions int he postauricular area just behind the ear lobes, with the cannula directed toward the submental and submandibular areas. This creates crisscrossed tunnels underneath the chin and helps smooth the contour of the submental region). B. Combined closed-open liposuction with rhytidectomy 1. closed is used to assist the manual dissection of face lifting utilizing the cervicofacial flap, pretragal flap, posterior cervical flap, and submental, submandibular flap. The area of the rhytidectomy is pre- tunneled and then liposuction carried out over the area to be elevated for a classic rhytidectomy. Next, skin flaps are raised by transecting the septa between the liposuction tunnels. 2. this method of liposuction does almost half of the dissection work for the rhytidoplasty procedure; this method also markedly decreases operative time and is felt to allow a much safer flap elevation than classic method of rhytidectomy. 3. after flaps are raised, the cannula is again used to remove fat superficial to the SMAS and platysma under direct vision. By using a gentle back and forth motion the fat tissue is ruptured and removed. 4. Mladick estimates that 50% of facelift patients can benefit from liposuction in these six areas: a. submental b. submandibular c. preparotid d. lower nasolabial e. upper nasolabial f. malar fat pad areas. C. Dressings are required post operatively to obtain: 1. compression to prevent hematoma or seroma formation 2. redrapping of skin 3. even compression of all areas suctioned to prevent dimpling and puckering 4. no sunlight exposure for 6 months X.Complications (all rare after #A) A. Skin 1. dermal injury from vigorous suctioning and taping 2. taping skin directly with adhesive tape will often result in vertical wrinkling 3. if place tape across midline from one side of mandible to other, may cause vertical wrinkling and dimpling of submandibular area and jowls B. Rare hematoma or seroma formation C. Rare injury to facial nerve or greater auricular nerve D. Infections E. Skin necrosis - primarily in smokers! F. Skin slough - primarily in smokers! G. Fat embolism H. Fasciitis and abscess I. Paresthesia J. Hypotension K. Pain L. Prolonged drainage M. Thrombophlebitis N. Skin Pigmentation Changes XI. Lipoaugmentation A. Very controversial as to whether or not is actually effective due to the high resorption rate. B. Preoperative evaluation should make sure that the defect is indeed subcutaneous and not intradermal, since autologous fat can augment only the subdermal deficiencies. Intradermal correction can be done at the same time with chemical peel and collagen injection if needed. B. Argis recommends six areas which responds well to lipoaugmentation: a. glabella frown line b. inframalar groove c. cheek hollows d. nasolabial fold e. oral commissure f. and mentum. C. Preferential donor sites 1. inner part of knee 2. dorsal regions of buttocks 3. lateral thigh 4. abdominal region D. Should overcorrect approximately 50%( this is variable and some state only 20-30%) as absorption rate varies between 20 - 60 %. E. Reported advantages: 1. is an autograft, thus no immunity phenomenon 2. easily obtained 3. can be repeated several times 4. low cost 5. some say results very satisfactory, but many disagree. F. Pointers when performed: 1. avoid high negative pressure during suction 2. use adequate instruments - 18-20 gauge needle 3. avoid "collections" or "lakes" 4. inject in "rod" or "thread" shapes while withdrawing in 0.1ml increments. 5. overcorrect 20-30% 6. rest grafted area for at least a week 7. antibiotic prophylaxis 8. perform light massage of grafted area 9. use molding adhesive tape for 1 - 2 weeks G. Complications 1. local inflammation 2. injection outside of planned area 3. infection ----------------------------------------------------------------------------- BIBLIOGRAPHY 1.Adamson PA, et. al. "Cervicofacial liposuction: results and controversies." Journal of Otolaryngology. 19:4; 267-273, 1990. 2.Aguilar EA and McCutcheon CK. "Cervicofacial Liposurgery." 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