Before making incisions, flap elevation with lipodissection is accomplished. The term is derived from the use of liposuction cannulas used for dissection rather than suction. In fact, very little liposuction is even completed. We have found from past experience that the technique of aggressive facial liposuction, although often providing good initial results, often led to later changes that were undesirable as patients aged. Patients who were followed for long periods have an excessive loss of subcutaneous tissue from aggressive liposuction surgery in the face, neck, and jowls. We now limit suctioning to areas in which there is truly a fatty tissue excess. This will generally be in the jowl and submental areas. Suctioning along the anterior jowl with microcannulas can be very useful but, again, fat removal should be conservative. In the submental area, there is often excess fat. In this case, we will do liposuction but we avoid removing all the fat between the anterior bands of the platysma muscle to avoid producing a hollowing effect in this area, sometimes referred to as a "cobra neck deformity."
The lipodissection is accomplished by using small cannulas of diameter varying from 1.5 to 2 mm. Approaches are made through punctures just in front of the upper attachment of the helix of the ear, below the lobule, in the mastoid area and in the submentum. A small trochar is used to puncture the skin, lipodissection is carried out using a very gentle movement. The small cannulas should easily identify the subcutaneous plane above the deeper musculofascial layers.
In all cases, the cannula opening is down, facing platysma, and not toward the undersurface of the skin to prevent injury to the dermis which could cause skin dimpling. The extent of lipodissection extends from beneath the zygomatic arch anteriorly beyond the extent of the parotid gland, partially overlying the masseter muscle. Along the angle of the mandible, suction is carried out toward the chin. While approaching the chin, it is critical to remain in a superficial plane since the mandibular branch of the facial nerve is quite superficial in this area and is not covered by muscle. It is very important to carry the lipodis-section far forward toward the chin to facilitate release of mandibulocutaneous attachments in that region. Adequate rehabilitation of the jowl is dependent on this release. In the neck, dissection is carried down to the hyoid and posteriorly to the sternocleidomastoid muscle.
Overlying and posterior to the sternocleidomastoid muscle, there are often thick attachments between the skin and the deeper structures of the neck and it may not be possible to develop a superficial plane with the cannula. If there is resistance in this area, we desist and depend on later sharp dissection. This is also true in the posterior triangle of the neck. It is important to avoid going too deep in the posterior triangle as the spinal accessory nerve may be at risk. We avoid all lipodissection beneath the hair bearing skin in the occipital scalp to avoid damage to hair follicles, which can easily result in permanent alopecia.
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