Atlas Kỹ Thuật Hút Mỡ (Atlas of Liposuction)

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Atlas of Liposuction
A
FIGURES 17-9A TO C
(A) Preoperative 59-year-old woman with flank redundancy
and thoracic rolls especially more severe on the right,
secondary to scoliosis; (B) Markings in place for a hip lift
procedure useful for thoracic rolls and buttocks and thigh
lifting. They could conceivably encompass more skin
excision, however, with an older patient it is safer to leave
some slack to the skin for fear of vascular difficulties; (C)
Postoperative
Excision of the Ellipse
A line is designed limited above by the back, flank and
abdomen and below by the buttocks and thighs. The
excision lines are marked above and below this line
designed to stay within the bathing suit area. These lines
are determined by the extent of excision necessary and
visible depending on the existing deformity presented by
each patient.
A transverse resection of the inferior redundant
buttock and thigh skin is performed after proper
liposuctioning of the area. Skin undermining is performed
down to the saddlebags area releasing the hip attachments
of the superficial fascia system that are the sites of the
lateral gluteal depression.
The transverse resection of the superior back, flank
and abdomen is performed ending the elliptical skin
excision superiorly. The skin is undermined to free the two
flank fixed points responsible for flank waviness.
The correction of the flank waviness is due to two
factors. The liposuction of the area is performed, however,
in view of the undermining to be done at the excision
stage, no attempt is made to free the fixed points
responsible for waviness by suction alone. Once the skin
has been excised superiorly, undermining is performed
over the ribs up to the lower level of the scapula, thus
freeing the “fixed points” and tightening the flank skin.
Repair is done in layers including the superficial fascial
system (SFS) and the dermis. This operation presents the
advantage of correcting the flank laxity as well as the
thigh laxity and it can be safely combined with liposuction
since it does not cut across vascular territories. It can even
be combined with an abdominal lipectomy providing again
that the vascular territories are not violated.
The Dowager’s Hump
The Dowager’s hump is a very unsightly deformity
secondary to fatty accumulation in the subnuchal area and
upper back (Figure 17-10).
FIGURE 17-10
Dowager’s hump
Anatomy
It is situated below the seventh cervical vertebra and
occupies the upper part of the back down to the eighth
thoracic vertebra. The hump can be quite large. It is
centrally located and rarely reaches the outer limits of the
scapula.

143
Back and Scapula
No specific treatment existed in the past. With
liposuction, an almost complete cure of the deformity
without major sequelae or untoward effects and minimal
scarring can be accomplished.
Indications
Any Dowager’s hump can be treated since the fat is well
contained and there is no major organ or neurovascular
element involved in the area. Any age is adequate and the
usual indications for any type of surgery applies. As far
as the specific indications for this procedure, there are no
contraindications since the skin should drape properly.
Caveats
Again, as mentioned, no specific problem can be
encountered except for the surgeon’s own resistance to
extract the fat completely from the area leading in these
cases to incomplete removal and possibly irregularities,
depressions, and bumps.
Technique
The operation is best performed in the lateral decubitus
position. If the patient is lying on her side, it is preferable
to position her with the right side up if the surgeon is
right-handed, or the opposite if the surgeon is left-handed.
In cases when the surgery is to be performed under
local anesthesia, the seated position can be used, the head
resting on both arms of the patient, thus allowing
downward suction with the cannula below which makes
it easier for the surgeon.
Instruments
4 mm and 3 mm cannulas usually suffice for this type
of procedure.
Postoperative Care
The patient is bandaged as usual using Elastoplast or
compressive garments after the wound has been closed
with one absorbable suture, and exercise and activities are
allowed approximately 10 days after surgery.
In conclusion, this is an easy procedure for liposuction
if the localization of the Dowager’s hump is accessible
on the patient.
References
1. Regnault P, Daniel R. Secondary thigh-buttock deformities after
classical techniques. Prevention and treatment. Clin Plast Surg.
1984;11(3):505-51.
2. Baroudi R. Flankplasty: a specific treatment to improve body
contouring. Ann Plast Surg. 1991;27(5):404-20.
3. Lockwood T. Body contouring of the trunk/thigh aesthetic unit.
Plast Surg Nurs. 2003;23(3):110-3.
4. Pitanguy I. Trochanteric lipodystrophy. Plast Reconstr Surg.
1964;34:280-6.

18
Arm Liposuction
General Principles
In younger patients with taut skin, the results of arm
suction are usually gratifyingly smooth and homogenous.
Older patients, on the other hand, often end up with
hanging skin, irregularities and bumpy areas. The surgeon
should, therefore, be aware of older patients.
Fatty deformities of the arms are, however, most
common in older patients. The deformity is either one of
A B S T R A C T
In younger patients with taut skin, the results of arm suction
are usually gratifyingly smooth and homogenous. Older
patients, on the other hand, often end up with hanging skin,
irregularities and bumpy areas. Fatty deformities of the arms
often seen in association with regular obesity are the
primary indication. Patients with large fat deposits and
hanging skin will only respond to an arm lipectomy with a
large excision. All patients, especially the older ones, should
be warned that irregularities and incomplete removal can
be observed after suction. Preoperative markings are of
extreme importance. Circumscribe the desired area with the
patient standing with the arms in the victory position.
Complications in the arm usually consist of hanging skin,
irregularities, bumpy arms and insufficient removal. Fat
excess with insufficient removal and irregularities are the
most common problem.
circumferential obesity from the elbow up to the shoulder,
or in most cases, an excess of fat localized in the
posterior tricipital area of the arms with a more normal
less fatty skin present anteriorly in the bicipital area.
In addition to the excess of fat, skin laxity will lead
to ptosis of the posterior arm especially in older patients
and in any patient after massive weight loss. As is the case
in other parts of the body, excess skin will not fully
contract after liposuction resulting in an accentuated
deformity with ptotic, hanging, thinned-out skin. The
cosmetic result in these cases can be greatly improved if,
in addition, skin excision is performed and it will be
shown in the next chapter.
Indications
Fatty deformities of the arms often seen in association
with regular obesity are the primary indication. The same
deformity may be also seen in older patients with
moderate obesity because some patients will develop a
particularly large deposit in the arms. The ideal case is,
however, a younger patient with taut skin and moderate
arm deposits occupying probably only one-third to one-
half of the arm gvolume and geographic distribution.
Contraindications
Patients with large fat deposits and hanging skin will only
respond to an arm lipectomy with a large excision.
Adrien E Aiache

145
Arm Liposuction
FIGURE 18-1
Markings for arm liposuction. Notice the extension of the
markings over the posterior shoulder area
FIGURE 18-3
Markings: Standing, arms down; standing, arms at 90°; use of
the pinch for evaluation of the thickest area and the remaining
portion to leave untouched. The zone of feathering is marked
as a second line
FIGURE 18-2
Arm liposuction can be performed utilizing various incisions;
three favorite incisions are at the elbow, the axilla, and the
mid arm region respectively
Anatomy
The area involved with excess fat is usually the posterior
tricipital area and the deltoid area. A moderate layer of
deep fat is present in the posterior deltoid layer situated
above the fascia superficially. This anatomical situation
dictates prudent suction to avoid irregularities and
depressions (Figures 18-1 to 18-9).
Caveats
All patients, especially the older ones, should be warned
that irregularities and incomplete removal can be observed
after suction. The arm is a long tubular area of skin with
the weight of the fat pulling down and hanging with the
accompanying skin. Sensory disturbances can also be
noticed in some cases.

146
Atlas of Liposuction
FIGURE 18-4
Further extension of the markings over the shoulder in cases
with thick shoulder area. There is a deep layer of fat situated
below the fascia superficialis in that region
FIGURE 18-6
The posterior tricipital fat is in a junctional area at the upper
arm level and is often suctioned insufficiently. The picture
shows the revision necessary in the patient to ensure proper
defatting of the upper arm. This is usually done through an
axillary incision. Localized liposuction of an area is performed
under local anesthesia. This should be estimated carefully in
view of the fact that this area is often neglected and will then
remain excessive
FIGURE 18-7
Upper extension of the markings to thin out the broadest part
of the arm
FIGURE 18-5
Another advantage of the mid arms incision is that the
crisscrossing is helpful in correcting large arm deformities
thereby achieving a more homogenous result

147
Arm Liposuction
FIGURE 18-8
The elbow approach is technically easier to perform than the
axillary approach as it allows for a more extensive suction
Positioning
The patient is placed supine and the cannula is then
introduced through the axilla or below and behind the
elbow. The prone position is often used when other
procedures such as thighs and saddlebags are done
concomitantly, however, the supine position is the most
comfortable for the operator (Figures 18-10 to 18-15).
Anesthesia
Although general anesthesia can be done satisfactorily,
local can be used. The tourniquet is not useful because
FIGURE 18-10
Supine position elbow approach. This is an easy technique
for posterior arm liposuction and concentration of defatting at
the most proximal posterior part of the arm which is often not
completely well suctioned
FIGURE 18-11
Prone position back approach defatting. In cases where the
prone position is used for other areas, this approach is useful
for the posterior arms. Additional suction is done in other
areas in that position
it is over the suction zone. Circumferential large extensive
suction is usually treated with general anesthesia.
Markings
Preoperative markings are of extreme importance.
Circumscribe the desired area with the patient standing
with the arms in the victory position. This will show the
excess situated in the inferior part of the arm and
posteriorly. Anteriorly, the skin is extremely thin and
suction in that area is an invitation to a catastrophe.
Palpation and pinch of the skin fold is used for
determination of the thickness to be reduced. These
markings are often delicate and difficult to locate
FIGURE 18-9
Unfavorable thin skin anteriorly does not retract fully and it is
flaccid and has very poor retractability and redundancy
leaving a very irregular zone

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Atlas of Liposuction
FIGURE 18-12
The axillary approach allows a thorough uniform liposuction
of the proximal arm region
FIGURE 18-13
The axillary approach will necessitate proper positioning of
the patient in order to be effective. It is sometimes difficult to
reach properly and an incision is made in the posterior
axillary fold to be able to reach the posterior arm
FIGURE 18-15
Postoperative dressings with Elastoplast are now abandoned
in favor of a circular compressing garment
FIGURE 18-14
The posterior axillary approach allows the proximal arm
defatting by direct approach in the prone position

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Arm Liposuction
satisfactorily and one has to decide the area of
demarcation with the untouched skin. The first marking
encompasses the area to be defatted and the second
circular marking indicates the feathering. The best areas
to improve are the deltoid area and the triceps area.
Further local markings are made as the surgeon
evaluates the arm. This is done with the arm down, up
at 90°, and then up. Visualization as well as palpation is
used to pinpoint the amount of suction to be used.
Circumferential visualization of the arm is especially
important. The area immediately above the elbow must be
checked for depressions and excesses since this zone is
sometimes extremely developed. The anterior demarcation
must be precisely determined to avoid difficulties. The
outer portion represents a judgment problem of where to
stop the suction. One has to imagine the area in a
tangential view in order to be able to correct it. The
unfavorable area is the anterior part over the medial biceps
and medial to it over the neurovascular bundles where the
skin is extremely thin over a moderately thinner fat
deposit. Do not forget the “groove” between the deltoid
and the biceps in the anterolateral view. The groove can
either be minimized by avoiding it during suction or
accentuated. Also, do not miss the uppermost posterior
area near the deltoid (Figures 18-16A and B).
In evaluating all these areas, the pinch test is used
constantly and routinely. It is the single most physical
evaluating tool besides vision.
It is useful preoperatively to mark the thickness
of skin to evaluate the improvement later on during the
case.
Instruments
In obese patients, 4 mm cannulas are used initially
followed by a 3 mm cannula for refinements. In thinner
patients, a 3 mm cannula is used throughout. Feathering
of the edge is performed at the end of the procedure
with the same cannula.
Incisions and Surgical
Technique
Short incisions are made in the axilla or in the posterior
condylar aspect of the elbow. The liposuction is done as
usual with a sawing motion using 10–15 back-and-forth
motions of the cannula until a satisfactory pinch test and
inspection is obtained. A secondary incision can also be
placed at the mid arms in more difficult cases. This will
remain relatively unnoticeable if before the incision the
infiltration with anesthesia is done, even under general
anesthesia using the tumescent solution. If one prefers it,
the ultrasound can be used in that zone as well as any
other type of suction mechanism. Extreme care is taken
in the procedure to achieve a homogenous skin thickness
FIGURES 18-16A AND B
(A) Preoperative 36-year-old woman with moderate arm lipodystrophy and ptosis; (B) Postoperative less than 125 grams of fat
was liposuctioned out of each arm. Note the thinning out without incidence of ptosis

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Atlas of Liposuction
FIGURES 18-17A AND B
(A) Preoperative 42-year-old woman with arm lipodystrophy and ptosis. Notice the large amount of tissue in the upper arm. This
indicates a poor result for that limited area. The measurement shows that the redundant part occupies more than 50% of the
posterior surface of the arm and this is a poor indication for a good result as shown by Illouz; (B) Postoperative
from the elbow up to the upper part of the arm.
Although the procedure is relatively bloodless, it is a
difficult task especially for the novice surgeon. Beware of
the moderately obese with very flabby skin (Figures
18-17A and B).
In more severe deposits, almost circumferential suction
will be necessary, however, in extreme cases combined with
excision of skin, the excision will follow the liposuction
procedure allowing an easier access to the remaining
deposits. Dangerous structures to keep in mind during the
procedure are the axillary vessel and nerves, the ulnar
nerve at the elbow, the olecranon bursa, and the radial
nerve at the outer lower portion of the arm posteriorly
(Figures 18-18 to 18-21).
FIGURES 18-18A AND B
(A) Preoperative 59-year-old woman with arm lipodystrophy and marked redundancy and flabbiness; (B) Six months
postoperative showing the skin excess with skin flabbiness that failed to shrink properly

151
Arm Liposuction
FIGURES 18-19A AND B
(A) Preoperative 52-year-old woman with bilateral arm lipodystrophy and obesity. Note the excess skin and flabbiness; (B) Six
months postoperative appearance on the same patient. In obese arms, although there are no irregularities in a well done job,
the skin nevertheless will hang and look empty from the back when the patients extend the arm. In these patients, liposuction
will often result in an “empty bag” phenomenon resulting from a lack of shrinkage which may last for a long time. Eventually
these patients will undergo a complete excision brachioplasty 2 years later
FIGURES 18-20A AND B
(A) Preoperative 35-year-old female with moderate arm lipodystrophy; (B) Ten years postoperative
FIGURES 18-21A AND B
(A) A mid arm incision is performed in cases of liposuction
where
finessing
is
necessary
and
difficulties
are
encountered in suctioning from the elbow or axilla; (B) The
same cannula is used for finessing and feathering
Complications
(Figures 19-22A and B)
Complications in the arm usually consist of hanging skin,
irregularities, bumpy arms and insufficient removal. Rarely
does one see sensory disturbances. Fat excess with
insufficient removal and irregularities are the most
common problem. No complications such as infection or
hematoma have been seen by the author.
Other possible complications include:
„
Irregular surface
„
Complications according to locations of the liposuction
–
Posterior: Less common
–
Medial: Very common, thin, unshrinkable skin
–
Anterior: Similar to medial, thin, crumpling skin.
A common complication is in the posterior arm that
will have bagginess if the excess fat deposits and skin is
considerable. Usually it should be less than 33–50% of
the surface of the arm, otherwise the skin will completely

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Atlas of Liposuction
FIGURES 18-22A AND B
(A) Preoperative 44-year-old woman with arm lipodystrophy; (B) Early postoperatively showing the residual bruising and
swelling
FIGURES 18-23A AND B
(A) Preoperative 26-year-old woman with mild obesity and bilateral arm lipodystrophy; (B) Six months postoperative
collapse and not shrink. To avoid this problem, careful
defatting should be done, crisscrossing, and one should
watch for dents and use only a skin cannula (Figures
18-23A and B). An excessive amount of liposuction will
end up with worse results than a conservative amount in
people who are relatively unsuitable for this surgery.

19 Combined
Brachioplasty and
Liposuction of the
Arms
Introduction
Arm lipodystrophies may result from any of several
factors. In adolescents, arm lipodystrophy can be indicative
of an ethnic characteristic as well as a family trait and
can appear as an isolated deposit of fat especially situated
in the posterior aspect of the arm. However, with
advancing age, arm lipodystrophies are most often seen
in patients with mild to severe obesity. In these cases, the
fat localizes in many areas including the arms.
A B S T R A C T
Treatment of the deformity of arm lipodystrophy has
consisted of large excisions of posterior skin with the
resulting scar placed in a non-conspicuous area such as
the medial part of the arm which is hidden when the
arm is against the chest. In spite of the effort to minimize
the visibility of the scar, few people accept such extensive
problems. The treatment in cases of extreme obesity is
liposuction. Ideal patients for the combination of
techniques are patients who have skin flabbiness, poor
skin tone, and who are older. In these cases, it is
uncommon to see any spontaneous shrinking of the skin
and the only treatment available is the brachioplasty,
however, even brachioplasty can be helped by liposuction
in the areas that have not been excised, thus allowing
a thinner arm and better scar with less stretching.
Treatment of this deformity consists of large excisions
of posterior skin with the resulting scar placed in a non-
conspicuous area such as the medial part of the arm
which is hidden when the arm is against the chest.
However, in spite of the effort to minimize the visibility
of the scar, few people accept such extensive problems.
The treatment, which is considered efficacious in cases of
extreme obesity, can now be offered in addition to plain
liposuction (Figures 19-1 to 19-3).
FIGURE 19-1
Longitudinal brachioplasty: Two different types of ellipse
excision can be used for brachioplasty. The liposuction is
only performed at the outer aspect of the ellipse that is then
excised in its total thickness
Adrien E Aiache

154
Atlas of Liposuction
FIGURE 19-2
Through axillary, elbow and mid arm incisions at the peri-
phery of the ellipse to be excised, the liposuction process is
undertaken to reduce the arm circumference and thus
facilitate the closure of excision
FIGURE 19-3
Appearance of the skin ellipse on a preoperative case
Indications
Ideal patients for the combination of techniques are
patients who have skin flabbiness, poor skin tone, and
who are older. In these cases, it is uncommon to see any
spontaneous shrinking of the skin and the only treatment
available is the brachioplasty, however, even the brachio-
plasty can be helped by liposuction in the areas which
have not been excised, thus allowing a thinner arm and
better scar with less stretching.
Patients who have very little excess fat and a large
amount of flabbiness and looseness will mainly benefit
from excision, however, patients who have a very large
amount of fat without excess skin might not be as
excellent candidates for this surgery.
Caveats
The patient should be warned about the usual difficulties
associated with liposuction such as irregularities, waving,
and over-removal or under-removal in addition to the
problem associated with a brachioplasty consisting of scar
irregularities and unevenness, depressions, hypertrophy in
addition to possible hematomas, seromas, infections and
lymphatic blockage which is sometimes the result of the
combination of these two modalities.
Markings and Preoperative Preparation
Markings are made on the erect patient and the patient
with the arm extended in the victory position. The
incisions are marked in the posterior epitrochlear area and
in the axilla, when fatty deposits are present and a
possibility of unevenness exists, the multiple approaches
can be used for an even result. The markings preferred
by the author are the very long S-shaped excision oriented
one way or the other which allow a scar with less tension
since the straight scars can create more difficulties than
this type of oblique, lazy-S fashion scars.
Excision Markings
After the markings for suction, the markings for excision
are made in an attempt to see the exact amount of skin
to excise. The area to be excised can be changed at the
time of surgery and the surgeon should start with only
a one-sided incision, do the undermining and then attempt
at possible closure which will determine the exact location
of the opposite excision of skin, thus assuring against any
problems of over-excision ending up in too much
tightness in the scar and in the circumferential area.
Technique
Longitudinal Brachioplasty and
Liposuction
A sinuous ellipse is drawn ending up as a sinuous scar
from the axilla to the elbow. At the level of the axilla,
it ends up with a turned-up scar as a hockey stick allowing
a transverse excision to improve the zone. The elbow
should be avoided, drawing the scar to end short of it
medially and to stay inconspicuous. If the scar is too
posteriorly placed, it becomes visible from the back. The
upper part of the scar should end up in the axilla with
enough tapering completed by liposuction to avoid any
dog ears. A very limited amount of undermining should

155
Combined Brachioplasty and Liposuction of the Arms
FIGURES 19-4A AND B
(A) Preoperative 52-year-old woman with bilateral arm lipodystrophy and skin redundancy. Note the markings for excision,
liposuction, and feathering in between the two areas to prevent sharp demarcation; (B) Six months postoperative. Notice again
the excision and the zone of feathering which could also be a complete zone of excision if it is judged to be necessary for proper
closure without tension
FIGURES 19-5A TO C
(A) A 45-year-old woman with arm lipodystrophy and skin excess and flabbiness secondary to large weight loss; (B) Six months
postoperative condition after liposuction and longitudinal brachioplasty; (C) The scars can be inconspicuous because they are
well-hidden in the medial part of the arm

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Atlas of Liposuction
FIGURE 19-6
Transverse brachioplasty. A small crescent excision in the
axilla will be sufficient to correct the slightly redundant skin in
older patients afflicted with loose skin. The liposuction can be
done from the axilla
FIGURE 19-7
An elbow incision can be useful to achieve regular
homogenous liposuction associated with the ellipse excision
FIGURE 19-8
Larger excision of skin in the axilla. In these cases, the
incision passes the limits of the pectoralis and the latissimus
posteriorly since the skin is in excess. This can be excised
and removed as marked by the dotted line
be performed for fear of vascular problems. During
surgery, the arms should be flexed and extended in order
to prevent esthetic difficulties (Figures 19-4 to 19-8).
Anesthesia
Depending on the size of the problem to be treated,
general or local anesthesia can be used. General anesthesia
is usually the most common in cases of extreme excess
of fat and extreme skin redundancy. An additional diluted
solution of epinephrine is used as a tumescent fluid for
reduction of blood loss.
Local anesthesia can be performed. It is done usually
on patients who are very cooperative and do not need
an extremely large amount of liposuction but mainly skin
excision. The local anesthesia can be done safely in these
cases with premedication and an IV with sedation.
Prepping, Draping and Positioning
The patient is prepped and draped in the routine manner
after anesthesia. In liposuction, the position is supine. The
blood pressure cuff is applied to the thigh. The arms can
be prepped and draped separately and are held by the
assistant during surgery. The local anesthesia of tumescent
solution is done and the suction is performed comfortably
from the axilla and from the pretrochlear area.
The Extent of Liposuction
The extent of suction can include the whole upper
extremity except for the medial bicipital area which has
very thin skin shrinking abnormally.

157
Combined Brachioplasty and Liposuction of the Arms
Postoperative Care
At the end of the procedure, bandages are applied and
a garment, relatively tight around the arm, is applied on
top of the bandages.
Transverse Brachioplasty
with Liposuction
In relatively moderate cases of arms lipodystrophy, the
excess skin is dealt with using an axillary excision. The
skin can be excised immediately and be followed by
liposuction. The ellipse in the axilla is marked with the
arms alternatively extended and flexed in order to check
the skin to be removed and prevent tightness. The ellipse
is then infiltrated with the local anesthesia solution and
the full thickness skin is excised. Liposuction of the whole
posterior arm is then performed and the wound is then
closed in layers. If the excess of skin is more extensive,
it is then necessary to excise an additional central portion
of the elevated skin in a longitudinal manner ending up
with a T scar which can be of limited length in order
to prevent visualization of the scarring and irregularity.
Treatment of this deformity consists of large excisions
of posterior skin with the resulting scar placed in a non-
conspicuous area such as the medial part of the arm
which is hidden when the arm is against the chest.
However, in spite of the effort to minimize the visibility
of the scar, few people accept such extensive problems.
The treatment, which is considered efficacious in cases of
extreme obesity, can now be offered in addition to plain
liposuction (Figures 19-9A and B).
Possible complications and how to avoid them
Complications Causes
Precautions to avoid
complications
Scar visibility
Anterior migration Careful defatting
Posterior migration Careful placement of
the scars. Anteriorly
past the humeral
groove to obtain a
good location
Side widening Zone poorly
suctioned
Tight irregular Uneven
zones
liposuction
TABLE
19-1
FIGURES 19-9A AND B
(A) A 54-year-old woman with slight lipodystrophy and loose skin; (B) Six months postoperative after liposuction and axillary
skin transverse excision
Postoperative Care
Massages and exercises are allowed approximately a week
after surgery.
Complications (Table 19-1)
Complications are of two types: (1) Complications asso-
ciated with liposuction consisting of bruising, hematoma,
dents, depressions, irregular areas of skin, and excessive
wrinkling of skin in the axilla or medially where the skin
did not drape adequately, and (2) Complications associated
with the excision lipectomy are the usual ones. They

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Atlas of Liposuction
consist of hypertrophic scarring, skin slough, wound
breakdown, infections, numbness secondary to the excision
of sensory nerves and irregularities secondary to improper
skin excision with inaccurate skin draping.
Although these complications are possible and have
been noted, they are relatively rare and are not a
significant factor in this surgery.
Discussion
The combination of liposuction and lipectomy of the arm
is a useful tool in cases where neither of the two
procedures would be adequate by itself. Although the scars
are extensive and as such are always a problem, this is,
nevertheless, the usual technique in patients who have no
other alternative. The complications associated with this
combination of techniques have been minimal.

20 Liposuction of the
Calves and Ankles
Introduction
The removal of fat from fatty ankles was first done by
Schrudde.1 This procedure consisted of making an incision
in the posterior area of the ankles, then using a curette
for removal of the fat below the gastrocnemius muscle.
Complications were relatively numerous for the procedure
to gain wide acceptance. Before Schrudde, a French
surgeon in the early 1900s had done this type of
treatment, however, a ballerina treated by curettage ended
up with generalized infection and lost her leg.
With the new technique of liposuction the improve-
ment can be quite significant.
A B S T R A C T
The anterior leg liposuction is performed on the prone
patient with the legs flexed in order to proceed
comfortably. It is often necessary to thin out around the
ankles to a maximum and allow more fat in the upper
leg at the junction with the gastrocnemius muscle belly.
Causes of dissatisfaction include lack of sufficient removal,
skin irregularities, asymmetries, edema, pigmentation,
pain and hyperesthesias. The technique of liposuction
of the calves and ankles is discussed with possible
complications.
Anatomy
In view of the fact that the fascia superficialis is adherent
to the muscular fascia, there is no fat deposits and the
superficial fat layer presents a dense connective tissue
associated with a florid lymphatic system. One needs to
use an even fat liposuction to prevent irregularities.
The anterior leg liposuction is performed on the prone
patient with the legs flexed in order to proceed
comfortably. It is often necessary to thin out around the
ankles to a maximum and allow more fat in the upper
leg at the junction with the gastrocnemius muscle belly.
Causes of dissatisfaction include lack of sufficient
removal, skin irregularities, asymmetries, edema,
pigmentation, pain and hyperesthesias.
Indications
Fatty lower legs are an indication when it is present below
the gastrocnemius muscle. The appearance of the legs is
deleterious to the esthetic in females (Figure 20-1). The
problem consists of fat deposits interspersed with some
fibrous tissue. It is found mainly in some ethnic groups.
The condition worsens with age and it should be
distinguished from dependent edema secondary to venous
stasis. Palpation and the pinch must reveal an excess of
fat since some of the ankle bulk may be due to edema.
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FIGURE 20-1
The pinch test is useful in assessing the thickness of the fat
layers around the ankles
Contraindications
Older patients with poor circulation, poor vascular supply
and extreme venous stasis are a contraindication since the
secondary problem can become serious. The skin tone
should be showing some adequate elasticity since in some
patients with poor circulation and brawny edema, there
is a very thick layer of fibrofatty tissue with lymphatic
engorgement.
Markings
The patient stands on an elevated stool so the exact
amount of fat can be assessed. The area is marked up
to the bellies of the gastrocnemius down to the ankle
itself and around the Achilles tendon. This zone is
extremely difficult since the circulation is poor in the
midline above the Achilles tendon and often is a cause
of superficial skin loss and even sometimes full-thickness
skin losses. The incision is usually made lateral and medial
to the Achilles tendon. More anteriorly, some fat deposits
may be encountered and they are suctioned through an
anterior horizontal foot incision (Figures 20-2 to 20-9).
Anesthesia
Depending on the extent of the suction, anesthesia can
be local but more often general. In cases with multiple
FIGURE 20-2
Incision medial to the Achilles tendon
FIGURE 20-3
From a median paratendinous incision, the liposuction is
carried out up to the level of the gastrocnemius muscle
feathering with a small cannula (3) at the periphery
FIGURE 20-4
Easy access to the ankle and lower leg is obtained through a
paratendinous approach either medial or lateral to the
Achilles tendon

161
Liposuction of the Calves and Ankles
FIGURE 20-5
Suction of the anterior ankle can be performed anteriorly from
any fold in front of the ankle
FIGURE 20-6
The suction process is often carried forward around the ankle
or can be performed with a secondary anterior incision
FIGURES 20-7A AND B
Notice the extension of the markings anteriorly so the entire circumference of the ankle can be reduced

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Atlas of Liposuction
FIGURE 20-8
Although relatively safe, an external ankle incision is
performed, however, be careful about the popliteal nerve
FIGURES 20-9A TO D
Ankle and knee liposuction combined for leg sculpturing. The
anterior and posterior midline are marked. If excess is
prominent in an area, it is marked with special markings. In
addition, the tumescent technique can be used in order to
reduce bleeding. An additional incision can be made in the
lateral part of the popliteal fold allowing suction of the lateral
leg down towards the ankle. In this figure, suction of the knee
is done in conjunction with ankle suction. Note the incision in
the knee that can be used for suctioning of the whole leg
anteriorly and posteriorly as well as the ankle incision and
can be used circumferentially for the whole ankle
suctioned areas, general anesthesia is preferable and the
legs are then infiltrated with the usual tumescent
infiltration. In local anesthesia cases, the same anesthetic
is used with some sedation.
Instruments
4 mm and 3 mm cannulas are useful. Finer cannulas are
used in order to prevent the untoward direction of the
cannula immediately below the skin creating dents and
longitudinal depressions.
Incisions
An incision lateral to the Achilles tendon in the ankle is
used. This should be avoided if the surgeon is concerned
about injuring the lateral peroneal nerve. Incision medial
to the Achilles is the most commonly used and allow a
proper suction of the whole medial posterior area of the
leg. A less common incision in the posterior popliteal fold
can be useful if there are extremely heavy deposits of fat
and the suction is done going downwards. Anteriorly, the
incision can be situated at the upper portion of the foot
and below the patella, either medially or laterally, allowing
then a proper suction in front of the tibial bone and
more medially over the tibia where more accumulation can
be seen. An additional incision can be made in the lateral
or medial part of the popliteal fold and this allows suction
of the lateral leg and ankle (Figures 20-10 and 20-11).
FIGURE 20-10
Bilateral incisions in the anterior ankle and knees as well as
in the posterior calves and knees allows complete
circumferential liposuction

163
Liposuction of the Calves and Ankles
Technique
The procedure is performed most often on the patient
prone and the anesthesia is infiltrated. Then the usual
“sawing wood” motion of the cannula is used in parallel
tunnels done in order and methodically in each tunnel,
trying to be even in the suction process. Proper
progression of the suction is checked continually by
palpation and observation using the pinch test and the flat
palm of the hand to assess the remaining thickness of
the skin below, on top of the cannula, and below the
hand. Although this defatting is adequate in most of the
cases, it has been found that vigorous defatting suction
is necessary to achieve a remarkable difference in the
shape of the ankles in some cases. Aside from circulatory
problems immediately on top of the Achilles tendon, no
other untoward effect has been seen from strenuous
suction. In other words, superficial suction is indicated in
these cases and it is the only possibility in the leg. While
0.5 cm is sufficient around the ankle, 1 cm will be
necessary in the upper leg supposed to be larger in
volume than the lower leg. To improve on the exact shape
of the results, a computer suction machine can be used.
It helps in comparing the fat removal on both sides (LS
1000 aspirator by MD Engineering, CO2536, Barrington
Co. Hayward, CA 94545) (Figures 19-12 to 19-14).
Refinements
Feathering at the junction of the defatted and non-
defatted areas is performed with finer cannulas and either
FIGURE 20-11
Medial and lateral incisions
FIGURE 20-12
Elastoplast can be applied in a crisscross fashion avoiding
circulating taping, however, compressive garments are
preferred immediately postoperatively
minimal suction or no suction at all. In addition, proper
defatting in a less aggressive manner is done anteriorly and
at the lower edge of the gastrocnemius muscle. The
refinements are made using a Robles 2.4 or 3 mm cannula
with either one or three openings. A proximal tourniquet
can be sometimes used when large amounts of fat have
to be removed, however, this has a negative effect of
extreme bleeding when it is released at the end of the
procedure in each leg. However, this technique has been
suggested by some and under proper circumstances, it
might be useful (Figures 19-15 to 19-18).
Postoperative Steps
Compression and massaging of the area is useful to
reduce the edema postoperatively. Once complete, defatting
has been obtained and the incisions are closed with
absorbable sutures reinforced by Steri-Strips, a garment
can be applied in addition to Ace bandages to prevent
deep vein thrombosis. The patients are asked to ambulate
ad lib and are allowed to have moderate activities. The
compressive garments are the most useful. A support hose
often reinforced by Reston foam is used sometimes (Ali
Med, 297 High Street, Dedham, MA 02026) and kept in
place with a 6 inches Ace bandage (Figure 20-12).
Postoperative Care
Patients are treated with prophylactic antibiotics as well
as pain medication, asked to stay off their feet or
ambulate, and are not allowed to have their legs folded

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FIGURES 20-13A TO C
(A) Preoperative 36-year-old woman with ankle lipodystrophy; (B) The lateral leg fatty excess marked for liposuction; (C) Six
months postoperative. Notice the larger knee and ankle on the left side. A more intensive liposuction in the left medial malleolus
area might have improved the results. Note the persisting discoloration and bruising of the posterior leg
B

165
Liposuction of the Calves and Ankles
FIGURES 20-14A TO C
(A) Preoperative 46-year-old woman with ankle lipodystrophy. Notice the markings for the liposuction up to the gastrocnemius;
(B) Six months postoperative showing the improved ankle shape but also some mild irregularities in the texture of the legs;
(C) Five years postoperative. The patient has gained 15 pounds of weight and has the same circulatory difficulties with skin
breakdown and discoloration

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FIGURE 20-15
In checking the postoperative appearance during liposuction,
it is often necessary to compare the legs by juxtaposition. The
placement of a straight rule between the legs give an
adequate estimation of the results
FIGURE 20-16
At surgery, the patient has the legs flexed to evaluate the size
and shape of the calf and compare it with the opposite side. It
is important to avoid step deformities due to a sudden change
in the fat thickness
FIGURE 20-17
Anatomically there is only one layer of fat between the
muscular fascia and the skin. It behooves the surgeon to
remain even during the suctioning. The anterior leg suction is
accomplished on the prone patient with leg flexed. It is often
necessary to thin out around the ankles to a maximum and
allow more fat in the upper area when it reaches the
gastrocnemius muscle

167
Liposuction of the Calves and Ankles
FIGURES 20-18A AND B
(A) Preoperative 32-year-old woman with ankle lipodystrophy; (B) Six months postoperative. There is improvement in the
posterior curve and the anterior ankle bulge. Note the excessive pigmentation and discoloration taking months to improve

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Atlas of Liposuction
FIGURES 20-19A AND B
(A) Preoperative 27-year-old woman with circumferentially heavy legs, anterior view; (B) Six months postoperative after
liposuctioning 225 cc of ft from each leg

169
Liposuction of the Calves and Ankles
FIGURES 20-20A AND B
(A) Preoperative 36-year-old woman with ankle lipodystrophy; (B) Postoperative. Note the improvement in the ankle contour

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Atlas of Liposuction
TABLE
20-1
Ankle liposuction contraindications
™ Circulatory problems
™ Varicose veins
™ Ankle edema
™ Raynaud’s syndrome
™ Lymphedema
™ Hypertrophic gastrocnemius muscle
Comments
™ Ankles with pitting edema should be a contraindi-
cation (Lymphatic or venous incompetence can be the
cause)
™ The skin tone should be showing adequate elasticity
otherwise liposuction is not advised
Liposuction complications
™ Insufficient removal
™ Excess removal and dents
™ Pigmentation
™ Edema
™ Pain
™ Hypoesthesia
™ Uneven or unequal
Remedies
™ Remove “plenty”
™ Conservative allows only token improvements
™ The skin should be 0.5 to 1 cm thin “all around”
TABLE
20-2
and be immobile. It is well-known that ankle suction is
the most painful after surgery since the ecchymosis,
edema, and post-traumatic reactions are unable to drain
downwards. The swelling and edema gives burning
sensations and difficulties in ambulation. Eight to ten days
after surgery, massages are encouraged as well as exercises,
drainage by elevating the legs, whirlpool treatments and
massages. The compressive stockings are worn for an
extended period of time, sometimes up to 6 months.
Patients will quickly learn to use them for their own
comfort. Sequential compression devices are used to lessen
the edema. They are started after surgery and can be
continued at home. The devices are applied from the
ankles to the lower thighs.
Circumferential Ankle Liposuction
Using the posterior and anterior approaches, circum-
ferential suction is used in fatty legs when a definite
increase in the anterior fat layers is palpated. It is
performed with a #4 or 3 mm cannula. It is safe
depending on the specific vascular condition of the
patient. Caution is advised in older patients with poor
vascular status for fear of local skin slough and venous
stasis and thrombosis. Through four incisions, the suction
is then performed and the upper incision can reach the
ankle and should crisscross the anterior midline. A
combination of a long 4 mm cannula and a 3 mm
cannula is sufficient to obtain good suction. Continuous
feeling and the pinch test will direct such a process and
combined with repeated inspection and palpation, it will
allow proper results and long-term postoperative results
(Figures 20-19 and 20-20).
Contraindications for ankle liposuction are given in
Table 20-1.
Complications
Some possible complications include infections,
irregularities and nerve injuries (Table 20-2).
Complications that are more common are swelling,
excessive pain for an extended period, some areas of
irregularities, extreme bruising and long-term duration
pigmentation.
Discussion
Liposuction has been found to be extremely useful in
cases of lipodystrophy of the lower legs. This technique
can bring dramatic improvement to these cases.
Contraindications are well-known and they include old age
with circulatory problems, varicose veins, ankle edema,
Raynaud’s syndrome, lymphedema and so on.
Determination of the exact desire of the patient will
determine the amount of fat removal. An aggressive
suction may lead to irregularities in the ankles but the
overall results will be better than cases that are done too
conservatively.
Reference
1. Schrudde J. Lipexeresis as a means of eliminating local adiposity.
Aesthet Plast Surg. 1980;4:215-26.

21 Facial Liposuction
Introduction
Multiple changes occur during aging. The most important
consists of the relaxation of the skin on its bed and
attachments over the superficial muscular and aponeurotic
system (SMAS). A second important change happens when
the deposits of fat situated in the young face change in
volume and vary in shape with aging. These variations consist
of alterations of the volume in the subcutaneous and sub-
SMAS fat deposits and specifically the decreased volume of
the fat and soft tissue in different spots. The areas of change
in the facial appearance consist of the following:
1. There is a decrease in the fat surrounding the mouth
causing wrinkles and deep lines situated along the skin
plications during speech and smiling and lip pursing.
A B S T R A C T
Facial aging results in fat loss in some areas and excess
fat in others. These volume increases in the fat distribution
can be treated by liposuction or by surgical removal. The
localized decrease of the fat can be treated by collagen
or by additional increments of fat deposition. These
combination of treatments is done in blepharoplasties,
face-lifts and the malar, submalar, mandibular and chin
implants. The treatment of special problems concerning
malar bags, Bichat and lateral buccal fat pads, sub-
platysmal liposuction, periorbital fat, melolabial fat, and
jowls is discussed.
2. There is an increase in the fat situated below the
eyebrows over the periosteum consisting of the retro-
orbicularis oculus fat (ROOF) as well as an increase in
the fat situated in the infraorbital area consisting of the
sub-orbicularis oculus fat (SOOF).
3. There is a decrease in the fat in the ear lobules causing
lengthening and distortion of the lobules with wrinkles.
4. There is an increase in the fat situated under the chin
and over the platysma giving the so-called double chin
deformity and there is an increase in the fat situated
under the platysma aggravating the conditions of double-
chin or “turkey-gobbler”.
5. There is a decrease in the fat situated under the malar
bones and lateral to the nose causing a triangular
depression in the middle cheek area.
6. There is an increase of fat in the jowls causing
redundancy associated with skin laxity which is blocked
by the retaining ligaments of Furnas in the chin area.
7. There is decrease in the upper forehead area causing deep
frown lines.
8. There is a decrease in the temporal fat pads causing a
gaunt appearance of the face.
9. There is sometimes a decrease in the orbital fat cushions
causing a cadaveric appearance of the eyes although at
other times there is an increase in these fat pads causing
palpebral bags.
These volume changes in the fat distribution can be
treated by liposuction or by surgical removal. The localized
decrease of the fat can be treated by collagen or by addi-
tional increments of fat deposition. These combination of
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Atlas of Liposuction
treatments is done in blepharoplasties, face-lifts and the
malar, submalar, mandibular and chin implants. All these
processes are combined to improve and rejuvenate the
face.
Indications (Table 21-1)
„
Early facial aging
„
Fatty face and neck
„
Postoperative unsatisfactory meloplasty (neck and jowls
only)
treatments and mini-lifts are the scarring which is
unwarranted on younger patients, especially males, who
often have a tendency to heal by hypertrophy and have
difficulties with limitations that the scarring poses on their
hairdo. These hypertrophic scars are most likely due to
the abundant amount of elastin and connective tissue
present in younger patients. Liposuction of the face alone
has brought a new weapon in the fight against facial aging
(Figures 21-1 to 21-13).
Indications for procedures in facial liposuction
Illouz division
™ Early stages of aging: Suction of the cheeks, jowls,
chin and neck.
™ Middle stage of aging with moderate skin redundancy
and sagging: Liposuction and mini-lift.
™ Advanced stage of aging with skin excess, sagginess,
and wrinkling: Liposuction and complete meloplasty.
Aiache division
™ Early and middle stages of aging: Liposuction alone.
™ Middle and advanced stages of aging: Liposuction and
complete meloplasty.
TABLE
21-1
Contraindications
„
Postoperative meloplasty which could give poor scarring
„
Thin face
„
Sagging face (old face)
Principles
In the past, early facial aging was treated through localized
area treatments, such as excisions of the nasolabial fold,
of the redundant skin of the chin with horizontal excision
or through the Z-plasty, and localized excision of the area
of the cheeks with a mini-lift technique. Injections, such
as the now outlawed silicones or the new collagens, are
used as well as the techniques of chemical peels and
dermabrasion.
In spite of these localized and limited modalities, the
best treatment for early facial aging is actually the face-
lift procedure.
With the advent of liposuction, the treatment has
made great strides; however, there are limitations and facial
liposuction-only gives the same clinical cosmetic results as
the so-called mini-lift. Problems with the limited surgical
FIGURE 21-1
The first step consists in liposuction of the cheek and neck.
A submental incision of 4 mm and a retroauricular incision of
4 mm is used for the procedure
FIGURE 21-2
Liposuction of the chin and cheeks through a chin incision of
4 mm that usually allows extensive neck and lower face
liposuction

173
Facial Liposuction
FIGURE 21-3
Liposuction, through a 3 mm incision, of the chin and neck is
accomplished by liposuctioning parallel with closely adjacent
tunnels
FIGURE 21-4
Liposuction is used alone for de-fatting the cheeks, jowls and
chin. Liposuction can extend to the lateral nasolabial area. It
is either done alone or in combination with face-lifting
FIGURE 21-5
With an angles cannula, it is possible to liposuction a large
part of the face including the jowls, nasolabial area and neck
FIGURE 21-6
Under local anesthesia, the whole chin and neck, as well as
he lower face, is essentially liposuctioned using an angled 4
mm cannula

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Atlas of Liposuction
FIGURES 21-7A AND B
Angled cannula
FIGURE 21-8
Through an inferior earlobe incision, the liposuction process
is continued and allows crisscrossing of the liposuction
FIGURE 21-9
The combination of two incisions allows crisscrossing
liposuction assuring a more homogenous removal of fat

175
Facial Liposuction
FIGURE 21-10
Facial liposuction in the unsatisfactory postoperative face-lift
patient. The preauricular and chin approach are indicated.
The cannula is introduced through a 4 mm incision in the
preauricular area, preferably at the anterior earlobe
FIGURE 21-11
To facilitate liposuction of the anterior cheeks and the
melolabial area, an incision is made in the nostril sill
FIGURE 21-12
Instruments moat commonly used for facial liposuction: 4 mm
angled Aiache cannula, 4 mm Fournier cannula 4 mm with 3
holes
FIGURE 21-13
Thinner cannulas, 3 mm, with multiple openings are used
most of the time in facial liposuction. They allow a fair amount
of liposuction in spite of their reduced diameter
Patient Selection
Indications
Younger adults, particularly those with chubby faces that
show only signs of sagginess and chubbiness of the
cheeks, jowls and neck, and those with a large submental
bulge and a large mandibular angle bulge which obliterates
the definition of the mandible. This problem is especially
distressful in males. In addition, there are patients
presenting with large Bichat’s fat pads creating the
“chipmunk” face.
The physical examination is done with the patient in
the standing position and smiling with neck flexed and
extended.
Evaluation of the areas to suction is done. The
mandibular border is marked in order to correct the jowls
properly. Note that since the jowls move up in the lying
position, they must be marked while the patient is sitting
up. Cases involving the nasolabial area also are marked
carefully noting that some areas may be more prominent
in the standing position (Figures 21-14 to 21-17).
One also has to be careful about the area just below
the chin border since often suction of the chin area can

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Atlas of Liposuction
FIGURES 21-14A AND B
(A) Preoperative 42-year-old female. (B) Postoperative following facial liposuction of the cheeks, neck, jowls, and nasolabial
areas. Note the more acute nasolabial fold resulting form emptying the melolabial fat
FIGURES 21-15A AND B
(A) Preoperative male. (B) Postoperative showing improved jowls and neck and accentuation of the nasolabial groove
FIGURES 21-16A AND B
(A) Preoperative 54-year-old woman with facial redundancy, severe wrinkling, and moderate tissue flabbiness. (B) Six months
postoperative after liposuction without skin excision

177
Facial Liposuction
leave a second little double chin. The area below the malar
bones is marked in the same fashion if someone is
interested in obtaining a hollow cheek appearance. As
mentioned, the markings are made in advance in the
sitting position (Figures 21-18A and B). At the limits of
the line encompassing the whole facial area from the
anterior auricle area down to the anterior portion of the
sternocleidomastoid muscle, extending superiorly to the
zygomatic arch with its apex at the nasolabial groove.
Medially, it extends below the edge of the nasolabial
groove to the lateral commissure of the mouth and down
inferiorly to the midline joining the opposite area. The
nasolabial area lateral to the groove or melo-genial groove
and superior to the fold is marked. The jowls are marked
in the erect position, as mentioned.
The pinch test is useful all along during appreciation
of the fat. Cross-hatching marks are made in the most
prominent areas and the most wanting spots.
procedures, the anesthesia in pure liposuction of the face
could be either local or general with infiltration of
epinephrine to reduce bleeding.
Incisions
A 4 mm incision is made under the chin behind a crease.
A second incision is made behind the ear lobule on either
side. A third incision is sometimes necessary in the temple
to be able to crisscross the suction during suction of the
malar prominence if it is necessary. One could also use
the crow’s feet line for incision. Finally, an incision can
be made in the nasal vestibule or externally at the apex
of the fold of the nasolabial area.
Surgical Technique
The patient is prepped and draped, and after anesthesia
is infiltrated, the first incision is made under the chin
using an angled Aiache cannula or a straight Fournier 4
mm cannula and liposuction of the whole chin area is
done going laterally as far as possible. A counter-suction
is done from the posterior earlobe area crisscrossing the
suction in the neck. This incision allows ascending toward
the jowls and superiorly toward the corner of the mouth
and malar bone. Fan-shaped suction is done with multiple
strokes until a proper improvement has been obtained.
The cannula can be turned laterally on either side to thin
out the skin as much as possible in some areas. Multiple
strokes are performed until the surgeon is fully satisfied
by the resulting thinness obtained under control (Figure
21-19). The cheeks and the jowls are suctioned thoroughly.
The jowls are done with extreme care since they are
difficult to correct. Another specific area is lateral to the
oral commissure, where it involves a deposit of fat over
FIGURES 21-17A AND B
(A) Preoperative patient. (B) Postoperative
FIGURES 21-18A AND B
Markings of the area lateral to the melolabial bulge and jowls
for facial liposuction
Anesthesia
Similar to the choice of anesthesia for face-lifting

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Atlas of Liposuction
FIGURE 21-19
Neck suction lipectomy. Depending on the height of the hyoid bone in relation to the mandibular ramus, the removal of fat
liposuction will achieve different results in the contour of the neck. A low hyoid bone will prevent a sharp angle in the profile view
the folding of the geniolabial muscle and lateral to it. The
liposuction in this area can possibly end with depressions
along the skin attachments to the muscle; however, it
improves the deposits of fat situated in this zone (Figure
21-15).
Refinements
Feathering various areas, especially the malar area just
above the cheeks and in the nasolabial prominence is
necessary to improve the look. Tiny incisions are added
in the zygomatic area and in the chin prominence to
reduce the whole volume of soft tissue of the chin. The
refinements can be an additional benefit in cases of the
“witch’s chin look” that is sometimes obtained after
complete de-fatting of the neck when there is hypertrophy
of the chin and a drooping chin.
Closure is performed absorbable sutures and Steri-
Strips are applied.
Dressings
Patients are dressed either with a 4 inch Ace bandage
around the face and neck or special facial masks that have
been developed and are useful in this early postoperative
period.
Postoperative Care
The patients are discharged and are able to go home with
antibiotics and pain medication. They are encouraged to
wash their face as soon as possible and apply the mask
to prevent swelling of the tissues. After ten days, they are
allowed to have massages and sometimes ultrasound.
Discussion
Liposuction of the face is a new modality of treatment
of early facial aging. Although limited in its scope, it is
done by some surgeons who want to improve the patient’s
facial sagginess and fat excess without having the scars
that are given by the face-lift procedures (Figures 21-20A
and B). The revival of this technique using ultrasound
suction is underway.
Conclusion
This technique is useful in well-indicated cases and will
bring satisfactory results with a complete absence of
scarring.
Special Areas
Malar Bags
Although sometimes improvement can be obtained by
wide, low skin undermining, the malar bag area can also
be improved by liposuction through two incisions. It can
also be improved by individual incisions: (1) Crow’s feet
line, (2) during a meloplasty procedure and (3) during a
blepharoplasty procedure.
Malar bags lipodystrophy is often a difficult problem
(Figures 21-21 to 21-24), although some attempts have
been made to accomplish de-fatting of the inferior border
of the orbit, it usually does not give an acceptable result.
Another way consists of elevating the inferior lid skin flap
that allows the technique. The development of the mid
face-lifting has put a new interest in this zone. Liposuction
can be useful in many instances.

179
Facial Liposuction
FIGURE 21-22
Markings for facial liposuction of the cheeks, neck, chin and
jowls on a 44-year-old female
FIGURE 21-21
A 48-year-old female with malar bags (sub-orbicularis oculus
fat excess)
FIGURES 21-20A AND B
(A) A 36-year-old woman with facial redundancy and lipodystrophy. Note the lack of definition or angularity in the features.
(B) Six months postoperative
An approach that be sometimes used is the pyriform
area incision through the buccal vestibule. The liposuction
is done in the usual way reducing the malar bags
protuberance until a satisfactory appearance is obtained.
Bichat Fat Liposuction
The indications for Bichat fat pad suction consist of the
chipmunk facies (excessive fatty deposits in the lower area
of the cheeks) which cannot be properly improved even
after face-lifting. In these cases, it is useful to reduce these
areas in order to sculpture the face properly (Figures
21-25 to 21-27).
Anatomy
The fat pad was described by a French surgeon, Bichat.
It consists of a fat pad situated in the cheek between the
masseter muscle and the buccinator muscle under the
SMAS. It has an upward extension into the zygomatic
fossa and the temporal fossa. It is related to Stensen’s
duct and to the facial nerves as well as the facial artery

180
Atlas of Liposuction
FIGURE 21-23
Malar bag or sub-orbicularis oculus fat suction lipectomy can
be performed through a blepharoplasty incision
FIGURE 21-24
It is possible to do cheek liposuction and in some cases malar
bag or sub-orbicularis oculus fat liposuction through a face-lift
incision
FIGURE 21-25
Bichat’s fat pad
FIGURE 21-26
Cross-section of skull and facial bones showing Bichat’s fat
pad and its relationship to the facial musculature
and vein. This fat pad is surrounded by a capsule that
has to be broken in order to extirpate the fat. Its
existence facilitates the motion of chewing. The surgical
approach is performed either through the mouth or
through a face-lift incision when the deep face-lift
technique is used. The fat pad is not to be mistaken for
the jowls which are the consequence of skin ptosis with
some adipose tissue plicated and blocked by Furnas

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Facial Liposuction
FIGURE 21-27A AND B
(A) Preoperative 56-year-old female with Bichat’s fat pad. (B) Postoperative following face-lift and liposuction of Bichat’s fat pad
ligament. The removal of the fat pads accentuates the
malar prominence giving a hollow-cheek look that many
women are interested in. Some patients having excess fat
pads have the chipmunk appearance. The incision for the
approach to the fat pad is either superior or inferior to
Stensen’s duct. During surgery, care is taken to identify the
orifice of Stensen’s duct. If the opening is difficult to
identify, massaging the parotid gland gently will allow
saliva to indicate the exact opening.
Caveats
It is imperative to do a careful suction since excessive
removal of the fat can create unsightly depressions and
thinning of the cheeks giving a cadaveric appearance. This
is especially true if this fat pad is suctioned on patients who
have insufficient skeletal support to their facial architecture.
Markings
Markings are made on the cheeks. The markings are also
made in the buccal mucosa mainly above or sometimes
below Stensen’s duct for the approach.
Technique
During the face-lifting approach, the technique consists of
elevating the skin flap deeply until the fat pad is
demonstrated. This type of approach is done when the
undermining is extensive up to the fat pad area.
Through the intraoral route, the approach can be done
in conjunction with a face-lift or without it. The incision
is made over the premolar in the superior sulcus and
introducing the cannula immediately in the fat pad area;
the suction is turned-on. The fat pad is teased out of the
oral cavity with suction and pick up. If it does not show
right away, spreading the tissues with a clamp to avoid
cutting the facial nerves is done until the fat is visualized.
A sufficient amount of fat is removed using a
combination of teasing out the fat and suction. The
mucosa is then closed with absorbable sutures or silk.
Complications
The two most common cause of complications consist of
nerve damage and depressions.
Nerve damage is only occurring when an aggressive
suction is performed either by the intraoral route or the
face-lifting approach. It is usually transient and a full
recovery occurs within a few months.
The most devastating complication consists of
depressions and emptying of the cheeks with excessive fat
pad suction, in cases where a facial suction is done in
addition to face-lift.
Aside from avoiding such problems, the treatment
consists of repeated autologous fat injections to restore
some of the contour of the lower jaw.
Sub-platysma Liposuction
Sub-platysmal fat suction is beneficial on younger patients
and can be performed with facial suction and pre-
platysmal fat suction. By contraction of the platysma
muscle, evaluation of the fat situated over and under it
can be performed. Relaxation of the platysma will allow
the pinch to grab the pre- and post-platysmal fat; as the
pinch will only grab the pre-platysmal fat when the
platysma is contracted. If the platysma is flaccid, it should
be tightened or excised at the time of surgery. If it is
thick and shows a short neck with an open cervical angle,
the excision or plication is necessary in addition to face-
lifting. Platysmal surgery is more efficient when associated
with face-lift.
Another useful approach in the pre-platysmal fat
problems is the release of the hyoid muscle which is
attached to the mandibular border through the geniohyoid

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Atlas of Liposuction
muscle. This can be released in releasing the origin of the
geniohyoid muscle just below the mandibular border. Thus,
allowing the hyoid bone to snap backward, creating a
better angle under the chin.
Indications for Sub-platysmal Fat
Patients are selected for the procedure by assessing the
fatty excesses present over and under the platysma. The
indication for sub-platysmal fat suction is derived by
assessing the amount of fat present under the muscle
using the technique mentioned above.
Sub-platysmal fat suction is of benefit on younger
patients and should be performed with facial suction by
attempting to judge if the pre-platysmal suction is
sufficient. By contraction of the platysma muscle,
evaluation of the fat situated over it and under it can be
performed. Relaxation of the platysma will allow the pinch
to grab the pre- and post-platysmal fat; however, the pinch
will only grab the pre-platysmal fat when the muscle is
contracting. If the platysma is flaccid, it should be
tightened and/or excised at the time of surgery. If it is
thick and shows on a short neck with an open cervical
angle, the excision or plication is necessary in addition to
face-lifting. Platysmal surgery is more efficient when
associated with a face-lift done in attempting to treat it
by localized surgery under the chin.
Caveats
Although it is obvious that the sub-platysmal fat will
improve the chin angle; it is, nevertheless, a problem and
only by releasing the hyoid bone it can be improved
completely if sub-platysmal fat suction is not successful.
This technique can become dangerous when encountering
vessels and nerves adding complications to the original
procedure. Sometimes under direct vision, the platysmal
membrane is incised after the enlarged chin incision has
been made exposing the whole neck area. The muscle is
retracted on both sides and the fat can be visualized and
suctioned either open sky or even removed surgically.
Periorbital Surgical Treatment
in Blepharoplasty
In performing a blepharoplasty, the treatment of the
surrounding tissues is sometimes of importance, and if
not accomplished at the original surgery, it becomes more
obvious and necessary after blepharoplasty (Figures 21-
28 to 21-30). Aging of the eyelids involves the lid skin
in addition to the junction of the cheek skin and some
FIGURE 21-28
Superior (retro-orbicularis oculus fat) and inferior (sub-
orbicularis oculus fat) periorbital fat pads
FIGURE 21-29
Forceps holding the supraorbital fat cushion (at the
supraorbital rim) while the hemostat holds the central orbital
fat pad (in the orbit)
eyebrow relaxation and ptosis. Above the upper lid, the
tissues consist of brow and soft tissue under it. The brow
itself descends and its ptosis is facilitated by the
supraorbital fat which cushions it under the orbicularis
muscle. This fat cushion is soft and its bulk and looseness
allows the eyebrow skin to move downward. The
treatment of brow elevation with buried sutures and fat
removal can be performed to improve this ROOF fat pad.
Only by removing this fat cushion, the position of the
brow can improve and stay more stable.

183
Facial Liposuction
FIGURES 21-30A AND B
(A) Preoperative 43-year-old female with supraorbital fat deposits. (B) Postoperative following fat excision from the brow area
At the level of the lower lids, the lid skin is often
redundant and relaxed and often associated with the
“eyelid jowls” present in the form of festoons, malar bags,
or even as the over-protrusion of the SOOF. The malar
bag and festoons can be corrected by different techniques.
The SOOF itself is an excess fat which is situated under
the orbicularis muscle and over the periosteum of the
malar area. Its suction or elevation during face-lifting can
improve the situation.
Anatomy
At the level of the orbital rim and above it, the fat
cushions are situated below the orbicularis muscle. They
are apparently more developed in the male in view of the
configuration of the supra-orbital area which exhibits a
concavity above the orbital ridges. The frontal bones are
covered by the fat pad which is crossed by the
supraorbital nerve and artery.
At the level of the lower orbital border, the fat
cushion is situated below the rim and occupies a space
above the periosteum and below the orbicularis muscle.
This pad is caused by the inferior orbital nerve.
Technique
Once the skin and fat pad extraction has been performed
on the upper lids, the fascia orbitale is split horizontally
along the whole length of the incision. The upper lid flap
containing the upper lid, the eyebrow and the orbicularis
muscle is elevated from the plane below by sharp and
blunt dissection. The fat pad consisting of the ROOF is
then identified, and it is dissected from the periosteum
below it up to the level of an ophthalmic vein crossing
the supraorbital area. It can be excised completely or
partially to improve on its appearance. Fine liposuction is
rarely advisable in such cases, although not altogether
contraindicated.
At the level of the lower lid, the dissection is
performed by elevating the skin muscle flap from the
septum orbitale below, and after visualizing the orbital rim,
dissection is continued below the rim, elevating the
orbicularis muscle with the skin for approximately 2 cm.
At this point, the fat pad is grasped from the superior
area and once it has been freed above from the orbicularis
muscle, it is freed from below freeing it from the
periosteum avoiding the infraorbital nerve zone. This fat
extracted represents the SOOF or a gliding tissue
necessary for lid movement. After hemostasis is secured,
the skin is draped and a suspension of the SOOF and
orbicularis muscle to a higher position over the periosteum
of the orbital border can be performed; thus elevating the
mid face. This type of surgery has been developed by
many surgeons including Hester, Vasconez and Shorr for
correction of the short lid and for elevation of the SOOF
to a better position. In less common cases, the SOOF can
be suctioned by any approach (face-lift, blepharoplasty,
intraoral or direct cutaneous approach).
Discussion
The surgical approaches in the esthetic improvement of
the orbital ridge area are procedures that have developed
recently and are necessary in surgical blepharoplasty
technique. Complications consist of numbness in the
eyebrow area, sometimes increased wrinkling of the lower
skin, and ecchymosis and hematomas; however, they are
very useful in the treatment of the periorbital esthetic
improvement of the face.
Melolabial Fat
This area remains the most difficult to treat.
Previous attempts consisted of direct excision of the
melolabial area leaving a large scar to replace the
nasolabial deep fold. Others tried to undermine the skin
and fill the groove only to see hypertrophy of the area
and thickening of the melolabial prominence. Suction
treatment often ends up in distortion and adhesion
secondary to uneven suction and poor draping of the
skin.

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Atlas of Liposuction
Incisions
„
Intranasal in the vestibule allows the suction to be done
in a fan shape on either side of the nasolabial fold.
„
At the lower end of the nasolabial fold, this is a direct
approach allowing suction of the melolabial prominence.
„
Distant approaches from the chin incision are very
difficult. The preauricular incision during a face-lift which
is the easiest, however, a large flap undermining is
necessary to reach this melolabial zone and then after
elevation, either liposuction of the zone or direct excision
of the fat is done as described by Millard.
Anatomy
The melolabial hypertrophy situated lateral to the
nasolabial fold becomes prominent in the early stage of
aging and weight gain. It becomes a difficult area especially
for men who have an over-developed melolabial
redundancy associated with deep nasolabial folds. It is due
to the redundancy of the cheek skin blocked at the
nasolabial line by the skin adherence to the zone of
junction of the orbicularis muscle with the zygomaticus
muscle and levator labii muscles. This zone contracts
during smiling; however, the distension of the skin with
age makes it redundant and the fold ends-up as an
anterior chin jowl similar to the jowl situated in front of
Furnas ligament in the chin.
Caveats
Patients should be warned about the fact that this area
is difficult to improve completely and that it is a
combination of fatty excess and skin redundancy. In
addition, emphasis should be placed on the fact that
suction alone will sometimes actually worsen the
appearance of skin excess ending-up in overhanging skin
in the melolabial zone over the nasolabial fold. Other
techniques are helpful for solving this problem, as
mentioned above.
Technique
Under local anesthesia, the melolabial zone can be
approached through any incision as mentioned above, and
it can be approached from above the nasal crease or
below the lower end of the nasolabial fold or from a
nostril. The suction is performed with a small cannula
palpating the skin in an area that is thinned out and
controlled with the pinch which should ideally measure
between 2 mm and 4 mm. Compression bandages are
helpful in the early postoperative period.
The combination of technique with face-lifting usually
is a better combination and improves the problem of skin
excess in addition to the melolabial redundancy which is
actually not an excess of fat but mainly a doubling of
the fat while the skin is folding. Techniques consisting of
the direct excision of the nasolabial fold with an ellipse
around. It is less popular and although it results in a fairly
acceptable result, they leave a long scar that is
objectionable to some people.
Jowls
The jowls consist of a redundancy of the lower chin skin
which is folding due to its relaxation thus doubling the
thickness of the fat situated under it. This folding is blocked
by Furnas ligament situated from the skin down to the chin
area. Furnas ligament’s blockage determines the actual jowl
which then can be corrected in different ways.
One way to correct it during face-lifting consists of
complete undermining of the area liberating the skin at
the level of Furnas ligament and elevating it and
tightening it over the buccal muscles. A second technique
consists of a simple liposuction of the area, which
sometimes is less than successful, since the skin will not
drape comfortably over an area that has been de-fatted
and will then create adhesions to the muscles below. It
has been found that excess suction in this zone can leave
deep furrows which are objectionable.
An isolated case of jowls liposuction can be
performed using small cannulas; however, the same
problems can result from the removal of the fat and the
adhesions secondary to the removal. These adhesions will
occur between the skin, which is redundant, and the
muscles below, which are moving, and in view of their
contraction, will worsen the look of the area. It is for
this reason that the choice is mainly of performing either
a meloplasty with jowl suction or a complete facial suction
with bypassing of Furnas ligament to liberate the skin and
allow it to contract more evenly.

22 Facial Liposuction
Combined with
Rhytidoplasty
Introduction
Prior to the use of liposuction, the results of face-lift
procedures were often unsatisfactory especially in the areas
of the jowls and under the neck as well as for the
nasolabial folds.
To be more specific, there were problems associated
with the redundancy of the jowls, the recalcitrant
nasolabial folds, and especially the fat of the neck which
was contributing to the “turkey-gobbler” deformity. These
A B S T R A C T
Prior to the use of liposuction, the results of face-lifting
procedures were often unsatisfactory especially in the
areas of the jowls and under the neck as well as for
the nasolabial folds. Liposuction has been of tremendous
help in contouring the neck, the angle of the mandible,
the nasolabial fold and the cheeks. The liposuction
technique is useful in complementing the face-lift
technique. It improves the appearance of the face,
improves in the removal of the unwanted fat and
improves in the overall appearance of the face. Excess
bruising, hematomas, rare cases of nerve paresis,
infections and skin slough are possible complications. New
problems occur as new approaches and applications of
the technique are developed especially the new
techniques of ultrasound and others.
problems were treated by direct excision of the fat
producing problems such as bleeding, adhesions, and
deformities secondary to the unequal excision of the fat
a technique which was producing problems such as
bleeding, adhesions, etc. In some cases where obesity was
associated with facial skin redundancy and droopiness, it
was especially difficult to obtain good results and the
patients were always disappointed. The obese patient was
often rejected as a candidate for face-lift and some of the
patients with excess nasolabial folds or jowls were
particularly unhappy with the results.
In order to improve the appearance of the face in the
face-lifting procedure, liposuction has been of tremendous
help, helping in contouring the neck, the angle of the
mandible and the nasolabial fold as well as the cheeks
which can be carved. This technique does not increase the
morbidity of the face-lift procedure and does not increase
the scarring.
Marking
The patients are marked either in the sitting or standing
position. The standing position is helpful in appreciating
the amount of nasolabial redundancy, the jowls and the
neck fattiness, and over-protrusion. The incisions are
marked in the temple, in front of the ear in a lazy-S
fashion going behind the tragus, around the earlobe and
the posterior mastoid area. The markings for undermining
are made as usual. The malar area is marked so that the
Adrien E Aiache

186
Atlas of Liposuction
liposuction is avoided in that zone unless it is requested
by the patient. The marking with ink is made as a triangle,
based laterally on the cheeks going toward the apex to
the nasolabial folds and along the nasolabial line into the
neck. These are the liposuction zones. In the neck, the
markings are made with the incisions in mind for the
liposuction, under the chin slightly away from the chin
crease to avoid the witch’s chin deformity. The markings
in the neck go below the chin to the hyoid bone level
and laterally above and along the sternocleidomastoid
muscle.
Technique
The patient is then in the supine position for surgery.
Anesthesia can be general especially in older patients or
relatively risky cases or in patients unwilling to undergo
local anesthesia. In more courageous patients, under local
anesthesia surgery can be done easily. It consists of the
usual anesthesia solution.
The surgery starts with incisions in front of the
earlobe and under the chin. Through these two incisions,
complete liposuction of the chin, mandibular jowl area
and laterally in front of the sternocleidomastoid is done
using the usual multiple strokes with liposuction using a
4 mm cannula and a 3 mm cannula for finessing. The
liposuction is then carried anteriorly from the anterior
earlobe incision and liposuction of the cheeks is done up
to the malar bone. The cannula goes to the nasolabial fold
involving, in addition, the melolabial mound which
constitutes the folding of the nasolabial fold blocked in
this area. Once the cheeks are satisfactory, completion of
the face-lift elevation is performed with the usual
preauricular incision and postauricular incision. The
undermining up to the midline of the neck, to the
nasolabial fold and to the second crease of the neck
elevating over the malar area up to the orbital commissure.
The skin is lifted and completion of the suction is
sometimes done using an “open sky” technique if there
is still an excess of fat situated between the skin and the
subcutaneous tissue area. At this point, the superficial
muscular and aponeurotic system (SMAS) is incised in a
hockey-stick fashion, it is elevated and tightened using
absorbable sutures then the skin is draped, the excess is
marked and excised, and it is closed using absorbable
subcuticular sutures.
Elevation of the skin demarcated which is done using
Metzenbaum scissors after it has been elevated with the
liposuction cannula. Before closure, the jowls and the
lower neck are liposuctioned as an open procedure while
checking the results of the closed liposuction. The open
liposuction is useful in the lateral buccal area which is
usually difficult. The undermining and the liposuction over
the labiomandibular muscles are done for a complete
improvement of that zone (Figures 22-1 to 22-10). It is
often noted nowadays in patients who have had a face-
lift that this zone has been left without satisfactory
removal of the fat, and draping of the skin leaving this
unsightly bulge on the lateral aspect of the oral
commissure. This combined procedure is useful since it
will complete the face-lift surgery.
FIGURE 22-1
The first step consists in liposuction of the cheek and neck.
A submental incision of 4 mm and a retroauricular incision of
4 mm is used for the procedure
FIGURE 22-2
Liposuction of the chin and cheeks through a chin incision of
3 mm

187
Facial Liposuction Combined with Rhytidoplasty
FIGURE 22-3
Liposuction of the neck can be extended to the border of the
sternocleidomastoid muscle and can go through the jowl area
FIGURE 22-4
The first step consists in liposuction of the chin and neck
through a 4 mm chin incision. The chin, neck and jowls, as
well as the remainder of the face in some case, are
liposuctioned through a preauricular incision placed in front of
the earlobe
FIGURE 22-5
The combination of the two incisions allows crisscrossing for
homogenous removal of the chin, neck and the jowls
FIGURE 22-6
The second step after liposuction: The face-lift flaps are
elevated by blunt and sharp dissection revealing the septa
left intact after liposuction and some remaining fat on top of
the platysma

188
Atlas of Liposuction
FIGURE 22-7
The third step: “Open sky” liposuction of the chin, neck and
jowls as well as the cheeks, the melolabial area and the
parabuccal area
FIGURE 22-8
When indicated, sectioning and plication of the platysma
fibers is done. Elevated, and plicated in a hockey-stick type of
incision
FIGURE 22-9
The medial vertical bands of the platysma muscle are
plicated after they have been sectioned at the level of the
hyoid bone forming a supporting hammock under the chin
FIGURE 22-10
The fifth step: Closure of the wound is performed over a
postauricular Penrose drain

189
Facial Liposuction Combined with Rhytidoplasty
Refinements are performed using a finer cannula
especially around the chin incision which often has excess
of fat especially around the chin incision when it is
associated with the platysma plication. Another step for
the refinements, as mentioned, is the peribuccal area.
Liposuctioning at the apex of the nasolabial fold and
melolabial mound, which often are redundant after the
face-lifting procedure and often, if not performed
sufficiently, will leave a relatively conspicuous sulcus and
melolabial mound. Fine liposuctioning can be performed
over the sternocleidomastoid muscle where the fat deposits
are relatively less conspicuous but more difficult to treat.
Since the SMAS tightening seems to accentuate the
protrusion of Bichat’s fat, the pocket is opened with a
clamp, extruding the fat pad and, by using suction, it
gently avulsed from its deep cheek location.
Dressings
The patient is dressed in the usual fashion. No effort is
made to drape the skin tightly by Elastoplast since the
flap has been elevated for fear of congestion and possible
slough of the flap.
Postoperative Care
Patients are discharged and the bandages are removed
within 48 hours. A postauricular drain is usually left
in situ and removed at this time. The patients are treated
with prophylactic antibiotics as well as pain medications.
In the neck, massages can be useful at a later stage to
prevent the adhesions from forming in this combination
of techniques. Ecchymoses and hematomas are treated in
the same fashion using massages and sometimes even
external ultrasound.
Discussion
The liposuction technique is useful in complementing the
face-lift technique. It has improved the appearance of the
face, improved in the removal of the unwanted fat and
in the overall appearance of the face, especially the cheeks
(Figures 22-11 and 22-12).
Complications of Facial
Liposuction Alone and in
Combination with Face-lift
(Figures 22-13 to 22-16)
Excess bruising, hematomas and rare cases of nerve
paresis when the liposuction cannula inflicts contusions to
the mandibular branch of the facial nerve; when the
liposuction is performed from under the chin and it is
turned around to suction the jowls and the angle of the
mandible. Other complications are seen rarely, such as
infections and skin slough, although the skin sloughs are
usually associated with excess skin removal with excess
tension on the flaps.
After the early days of enthusiastic use of the
technique of liposuction, its particular problems are
surfacing. The problems encountered were the following:
Facial Liposuction Alone
Cases of liposuction are usually reserved for young faces,
early aging and chubby faces. Problems have been
irregularities and depressions especially in the areas of the
jowls where the suction process has been too intensive.
In the neck irregularities and unevenness are often
found. In men, alopecia can result from liposuction of
FIGURES 22-11A AND B
(A) Preoperative 56-year-old woman with facial redundancy and fat deposits. (B) One year postoperative after meloplasty,
blepharoplasty and neck liposuction

190
Atlas of Liposuction
FIGURES 22-12A AND B
A 38-year-old woman with facial redundancy and neck excess
FIGURE 22-13
Skin puckering in the area of the nasolabial and parabuccal
folds after liposuction lipectomy on a postoperative face-
lifting case. The scar, already present does not respond well
to liposuction since the fat is compartmented in the scar
FIGURES 22-14A AND B
(A) A 66-year-old female shortly after facial suction lipectomy
and one year after meloplasty. No skin excision in the second
procedure. (B) The treatment eventually consisted of
rhytidoplasty with skin excision and tightening
FIGURE 22-15
Neck complications in cases of suction lipectomy performed
a second time or after a face-lift. The treatment consist of
massage, ultrasound and steroid injections
the chin in thin-skinned areas. The most common
distressing problem is seen in patients who undergo
liposuction of the face in cases done after a previous face-
lift has been done. In these cases, adhesions of the skin
develop with irregular bumpy scars along the zones of
suction. Irregularities, deep wrinkling and distortions have
been seen. Although physical therapy with ultrasound has
been used, the complications eventually necessitate a
second skin undermining and tightening in order to