History

Suction-assisted lipectomy or liposuction, although not an entirely new procedure, has changed significantly since being first introduced. Current methods of liposuction have seen significant advances in the aesthetic outcome while minimizing associated morbidity. Present-day liposuction differs extensively in several aspects from when it was first introduced. In 1921, Dr. Dujarrier from Paris attempted to improve the contours of the knees of ballerinas by removing the excess fatty tissue. This procedure was done through a small incision and utilizing curettes and scraping out the excess fat. These initial attempts at contouring of the body were not very successful because of severe infections that followed due to the lack of antibiotic coverage that was not introduced until decades later.

In the 1960s and 1970s, further procedures were being performed also with curettes to excise the fatty tissue. In 1972, Dr. Schrudde introduced the closed procedure known as lipexheresis that consisted of utilizing sharp uterine curettes to remove the excess tissue.¹ As with earlier attempts, morbidity was quite high and the search was on for a more successful procedure with fewer side effects.

In the mid-1970s, Drs. Kesselring and Fisher attached suction to their own curetting instruments.^2,3 This step represented the first major advancement in closed suction-assisted lipectomy techniques.

Later in the 1970s, Dr. Illouz was the first to clearly utilize liposuction the way it is used today.⁴ He designed newer and safer types of cannulae for closed liposuction systems. His cannula tip had blunter, rounder ends with suction apertures. In addition to his closed aspiration technique, he also infiltrated the operative sites with a hypertonic saline and hyaluronic acid-based solution. He thought that this solution would liquefy the fatty tissue, thus making the aspiration process easier to perform. The addition of the suction greatly facilitated this technique.

Further improvements to the closed liposuction technique were advanced by Dr. Fournier.⁵ He proposed that the instillation of the solution performed by Illouz was not necessary and only prolonged surgical time. He studied the aspirated fat and found it identical to his aspirated fat done by his “dry” technique that involved no infiltration of solution preoperatively. With time, however, it was noted that the dry technique had problems of its own including increased morbidity primarily due to increased blood loss and prolonged recovery. This problem was avoided by the instillation of dilute epinephrine mixtures done just prior to liposuction.

The first procedures in liposuction known as the “dry” technique are no longer used. It also required general anesthesia because there was no local anesthetic solution injected into the fat before the commencement of liposuction. In addition, as previously noted, extensive blood loss was encountered. From the amount aspirated, approximately 25–30% was blood.

The search was on for a better preoperative infiltrating solution. This led to the “wet” technique that also required general anesthesia. This method mandated the injection of approximately 100–150 mL of epinephrine-containing local anesthetic. Although the wet technique caused less blood loss than the dry technique, blood loss with the wet technique was still excessive and dangerous. Blood composed approximately 15–20% of the tissue removed by liposuction.

The next advancement was the “super wet” technique. Like the previous ones, this also required general anesthesia. With the super wet technique, dilute local anesthesia is injected that is less than half the volume traditionally used for the tumescent technique. Blood loss during surgery with the super wet technique is greater than with the tumescent, but substantially less than with the wet procedure. Approximately 8–10% of the fluid removed by super wet liposuction is blood.

The final advancement in infiltrating solutions, as well as that which is still currently used, is the “tumescent” technique. The word “tumescent” means swollen, turgid, and firm. By injecting large volumes of very dilute lidocaine and epinephrine into subcutaneous fatty tissues, the targeted tissue becomes swollen and firm, or tumescent. The lidocaine acts as a local anesthetic and the epinephrine acts as a vasoconstrictor. This method allows the surgeon to provide local anesthesia to large areas of subcutaneous fatty tissue while also minimizing blood loss. The procedure can therefore be done totally under local anesthetic, eliminating the need for general anesthesia or intravenous sedation. Blood loss is also significantly lowered and since large amounts of fluid are injected, volume replacement criteria are also achieved.

In addition to the traditional closed suction-assisted lipectomy or liposuction, two recent modalities have been introduced. These are ultrasonic-assisted and power-assisted liposuction. However, neither plays a major role in face and neck liposuction.

Ultrasonic-assisted liposuction requires the instillation of a large volume of tumescent fluid and uses a metal paddle or probe to deliver ultrasonic heat and energy into the subcutaneous fat. Internal ultrasonic-assisted liposuction is the technique where a long metal probe is inserted into fat through an incision. This procedure requires at least intravenous sedation and additionally has fallen out of favor because of the high risk of full-thickness and deep partial-thickness skin burns with associated scarring. External ultrasonic-assisted liposuction requires the use of tumescent fluid and utilizes the metal paddle applied to the skin surface. The ultrasonic energy is then delivered into subcutaneous fat. Like its internal counterpart, external ultrasonic-assisted liposuction does not offer any significant advantages to traditional tumescent liposuction and can also burn the skin.

Power-assisted liposuction has also been recently introduced. Power-assisted liposuction allows the cannula to rapidly move in and out or spin. This is accomplished by connecting the cannula to a power source that is driven by compressed air or an electric motor. Although power-assisted liposuction can somewhat reduce surgeon fatigue, there is still no clear-cut consensus on whether the advantages are truly worth it. For the face and neck, it really plays no significant role.

When liposuction was first described, it was not primarily used for the head and neck region. In fact, Illouz reported that only 4% of his patients undergoing liposuction had the face and neck treated.

Suctioning fat is not the only modality to remove it and improve the aesthetics of the face and neck region. Direct excision of the buccal fat pad and direct excision of deep, subplatysmal fat may also significantly improve facial form. These treatment modalities can be performed as isolated procedures or in conjunction with liposuction and rhytidectomies.

Anatomy and Etiology

Localized fatty deposits may be due to poor diet, exercise habits, hereditary factors, or hormones. The human adipocyte undergoes alteration from birth through puberty, after which it stops replicating, although each individual adipocyte can continue to increase in size with the accumulation of additional triglycerides. Although diet and exercise can decrease the size of the adipocyte, the actual number of these cells in the body remains the same. Liposuction removes those fatty deposits that are resistant to exercise, diet, and weight loss. If the localized fatty deposits are due to hereditary factors or hormonal reasons, these must be addressed separately. In fact, liposuction may be contraindicated in these cases, as one is not addressing the true etiology of the disease. If liposuction is indeed performed, the results will not be as satisfactory. Liposuction may be performed on almost all areas of the body where there is an excess of fatty tissue. This chapter will concentrate only on the facial and cervical regions of the body. Direct excisions of fat of the buccal region and cervical region will also be discussed. In young patients, the contours of the face reflect the underlying muscle and skeletal framework. The cheek eminence emphasizes the middle third of the face and the mandibular border emphasizes the lower third of the face.

Superficial cervical fat lies between the skin and the subcutaneous musculoaponeurotic system (SMAS). Whereas fat in the neck may be particularly abundant, especially in the submental area, it is much thinner in the face, rarely exceeding 4–5 mm in thickness.

Small neurovascular bundles traverse the fat but there are no major nerves or blood vessels superficially. The submental vein runs deep to the medial aspect of the platysma. The marginal mandibular branch of the facial nerve is on the lateral aspect of the subplatysmal fat. Adipose tissue in the cervical region may also be subplatysmal. It should be emphasized that liposuction should only be performed in the supraplatysmal plane. Deeper fat must be directly excised. This distinction must be made before any planned procedure.

Subplatysmal fat may be excised as a solitary procedure or in conjunction with platysmal procedures, rhytidectomy, or chin augmentation where an incision is already made.

The amount of adipose tissue removed from patients can vary greatly. The author has personally removed volumes from 25 to 175 cc. Cadaveric studies revealed fat volumes of the neck to range from 15 to 35 cc.

The buccal fat pad, also known as the fat pad of Bichet, was first described by Heister in 1732. Shane, in 1802, was the first to examine this entity. The buccal fat pad consists of a main body and four processes: the buccal, temporal, pterygopalatine, and pterygoid.

It lies in the space deep to the SMAS and superficial to the buccopharyngeal fascia. The pad lies just lateral to the buccinator muscle and buccal mucosa in the area of the maxillary second molar. The buccal branch of the facial nerve is positioned over its superficial aspect and the buccal branches of the trigeminal nerve run deep to it supplying sensation to the oral mucosa.

The fat pad is responsible for giving the cheek its prominent appearance, and in babies and small children it is needed for sucking and masticating. It also prevents the cheeks from collapsing.

Upon histological examination, the buccal fat pad is primarily composed of structural fat rather than accumulated fat. Therefore, it is not dependent on nutrition so even in cases of severe malnutrition it will be preserved. As one grows into the adult years, the buccal fat pad shrinks in all dimensions but its weight remains stable between 10 and 15 g.

Instruments and Suction

As with any surgical procedure, success is intimately associated with the skill of the surgeon as well as his instrumentation. Adequate suction and cannulae are of paramount importance for a successful outcome (Figure 12.1). Since cannulae were first utilized and introduced by Illouz, there have been significant advances in their construction and design. The head and neck region differs from the rest of the body in that the amount of fat is significantly less and is concentrated in a small area. Issues such as cellulite also do not affect it. Because of these reasons, the number of cannulae />