Liposuction of the neck and jowls can be performed with the machine-assisted or syringe-aspiration technique. Conservative removal of the jowl area is necessary but the neck can be more completely treated. The standard tumescent fluid is infiltrated until tumescence occurs utilizing a 0.1 or 0.15% lidocaine concentration. The treatment area in the neck should be limited to the area between the sternocleidomastoid muscles bilaterally. Rapid fat removal in the jowl can leave an unsatisfactory result owing to over-resection. The use of extremely small microcannula (18 or 20 gauge) will help prevent this complication. In contrast, thorough fat removal in the neck enhances skin retraction, revealing a significant clinical result. The neck is best approached through a crisscrossing pattern of microcannula liposuction. This is accomplished by ports in the submental region and infra-auricular sites bilaterally providing adequate interdigitation of lipoaspiration.
Most of the fat is located at a superficial level immediately under the skin. Care should be taken to avoid traumatizing adjacent and deeper anatomic structures. Aspiration of the neck should be performed with the usual grasping and pinching of the skin to avoid penetration through a dehisced platysma and damage to deeper structures. Potential complications include damage to the marginal mandibular branch of the facial nerve, persistent edema, damage to the platysma resulting in asymmetric facial movements, and trauma to the salivary glands. The submental site should not be utilized as a port for accessing the jowls because damage to the marginal mandibular branch of the facial nerve may occur where it crosses the mandible. Jowls should be accessed from the infra-auricular site. A 20-gauge cannula can also be utilized to aspirate the jowl immediately inferiorly, which provides the crisscrossing needed and leaves an almost invisible residual scar. The neck and jowls are delicate areas that require microcannulas to avoid skin contour irregularities and prevent damage to adjacent structures.
The outer thighs of women are also known as the “saddlebags” in the vernacular. This area often represents an isolated fat pocket that is effectively treated by liposuction. The adjacent cosmetic units, including the hips and buttocks, must also be evaluated and treated if needed to achieve optimal contouring. Frequently the hips, outer thigh, and buttocks are treated in a single session. The patient should be marked preoperatively while standing and viewed from the front. This will ensure that the peak point of the outer thighs can be identified. The outer thighs must be carefully treated to avoid contour irregularities. Meticulous attention must be maintained to ensure that enough fat is removed to produce a therapeutic effect, keeping in mind that excessive liposuction can produce indentations and depressions. The bulk of fat removal should occur in the deeper planes and superficial liposuction should be avoided. The area to be treated is teardrop-shaped, pointing distally where feathering into the distal lateral thigh occurs. One high-risk area that is susceptible to depression is the area of the bulge that forms above the greater trochanter of the femur. The bulge is augmented when the leg is outwardly rotated and adducted.
If aggressive liposuction is performed to flatten this bulge, it will actually produce a depression when the patient returns to the anatomic standing position; hence, intraoperative positioning is of paramount importance. The leg must be inwardly rotated and adducted to move the greater trochanter and remove the overlying bulge. If this positioning is not maintained, an indentation will occur over the greater trochanter. As patients are awake during the tumescent technique of microcannula liposuction, they can be positioned appropriately during the liposuction surgery. This is a major advantage of the tumescent technique. A triangular pillow (Thigh Midline, HK Surgical) may be placed between the thighs to ensure appropriate positioning. Three incision sites are made in the supero-posterior, supero-anterior, and infero-posterior positions correlating with the 2, 8, and 10 positions on the face of a clock. Less aggressive cannulas, usually 12- or 14- gauge Finesse cannulas, are preferred to gradually remove fat and sculpt the tissue evenly. The end point of liposuction in this area can be determined by visualizing a flat contour when the lateral thighs are viewed at eye level. Tactile evaluation through pinching of the tissue is also helpful in learning the end point of treatment of the outer thighs. The hips often contain copious amounts of fat that if left untreated will result in a less-than-desired outcome.
When treating the hips, it is essential that the liposuction be performed initially in the deeper planes. The cosmetic surgeon can then move more gradually to the more superficial planes. Without adequate removal of the deep fat in this region, a persistent bulge will occur. When treating the hip, the cannula entry sites should be placed on the supero-posterior aspect as well as inferiorly to ensure adequate fluid drainage postoperatively.
The inner thighs often require only very conservative lipoaspiration to achieve the desired outcome. This area is often a problem for patients not only owing to contour irregularity but also to chronic rubbing and irritation. By removing small amounts of fat, appropriate contouring can be achieved and rubbing of approximated tissues can be eliminated. This anatomic area has less elasticity and is especially prone to divots and dents if excessive or superficial liposuction is performed. In general, it is advisable to aspirate only the deep fat with minimally aggressive cannulas such as the 12- or 14-gauge Finesse cannulas. Access to the inner thigh is best attained with the patient lying on his or her side with the contralateral thigh flexed upward. Incisions are placed at the anterior and posterior aspects of the inner thigh in this position. An additional entry site can be placed more distally in the mid thigh to provide access from multiple directions for cross-hatching. It is important to treat and feather distally into the mid-thigh region and treat the medial knee if needed to produce a smooth contour of the inner medial leg.
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