S enescence is an inevitable dynamic process involving alteration in physiology and structure. In the skin, this is most evident in the dermis and underlying supporting structure of the adipose tissue and superficial musculoaponeurotic system (SMAS). Changes of the mature face include alteration of fat deposits. Often there’s a hollowing of the central cheeks, accentuating re-maining fatty deposits of redundant skin folds. This, combined with the cumulative effects of gravity and photodamage, contribute to an aged appearance. As physicians, we’re always seeking the most minimally invasive techniques, especially with patients who are in the early aging process. The trend toward less invasive surgery with decreased risks, less recovery time and less scarring is favored by most surgeons and patients. The Benefits of Liposuction Liposuction has gained favor over many open procedures, allowing for comparable aesthetic re-sults but with limited side effects.1 We’ve found that small instrumentation liposuction (microliposuction) applied to problem perioral areas, such as meilolabial folds and marionette lines and even into adjacent areas such as prominent malar pads, can result in significant aesthetic improvement for patients starting to manifest these changes, which typically become problematic by their late thirties to early fifties. This procedure may be performed under local anesthesia or utilized in combination with more extensive techniques such as laser resurfacing or rhytidectomy, which may require additional sedation. Pre-Operative Evaluation Evaluation of the patient’s perioral area for consideration of liposuction surgery should take into account several important aesthetic considerations. The cervicomental angle should ideally lie between 90 and 110 degrees, and the mandibular border should be well defined and oval to produce the most appealing contour and profile. Neck and jowl liposuction as sole intervention or in combination with other surgical procedures, such as rhytidectomy or platysmaplasty, may be used to address these issues. Reviews for these procedures have been recently published.2-5 Next, the cheek contour, malar fat pads, and meilolabial and marionette lines are evaluated. Often, early atrophic changes of the central cheeks begin to give a sunken appearance, serving as a stark contrast to and accentuating redundant skin folds of the meilolabial folds and marionette lines. The orbicularis oculi muscle relaxes with aging and repositions in an inferolateral direction. In response, the overlying malar fat pads are displaced anteroinferiorly, producing a “sad” appearance of worry and fatigue. If excess adipose tissue is present within these areas, minimally invasive techniques work well to remove the tissue with small instruments, which minimizes scarring and aids healing. The ideal candidate for this intervention displays early signs of aging and possesses good skin tone and elasticity as judged by a snap test — the skin is pinched between the finger and thumb and gently retracted from the face. A quick return to pretest contour portends a more favorable outcome. Delayed return or persistence of tenting of the skin may be an indication that rhytidectomy or another procedure in combination with microliposuction is more appropriate. Pre-operatively, topographic markings delineating the sites to be treated are made with the patient sitting in an upright position because this accentuates the redundancy, ptosis, or prominence of the problem areas. Care is taken to note the location of important underlying structures, notably the branches of the facial nerve. Most at risk is the marginal mandibular branch of the facial nerve as it traverses along the mandibular border. Remaining superficial to the SMAS/platysma at this site is prudent to avoid inadvertent injury to this nerve. Performing the Procedure If microliposuction is to be performed alone, only local anesthesia is necessary. If performed in combination with other surgery, supplemental sedation may be required for the more involved aspects. The patient is placed in a comfortable supine position. Points of entry are anesthetized with 1% lidocaine with 1:100,000 epinephrine. This is performed in the smile lines or lateral nasal ala for meilolabial folds, in the oral commissures for marionette lines, or in the crow’s feet for malar pads. A beveled nick incision with a number 11 blade is made to accommodate passage of a 1.5-mm infusion cannula attached to a 10-cc syringe. Dilute tumescent solution composed of 0.25% lidocaine with 1:250,000 epinephrine (1% lidocaine with 1:1,000,000 epinephrine diluted 1:3) with normal saline and infuse it in the superficial adipose layer to produce sufficient tumescence of the area to be treated. This not only provides the necessary skin turgor to facilitate fat extraction, but also serves to hydrodissect the proper plane for liposuction superficial to the SMAS. A 1.5-mm spatula cannula is then introduced along the same tract with the ports of the cannula facing down. The plunger of the syringe is drawn back to produce a vacuum, and the cannula is advanced in a fanned pattern over the areas to be treated. Make sure that you see fat flowing into the syringe. The “smart” hand may help to guide the cannula by pinching the areas to be suctioned. The process continues with frequent assessment of skin thickness by rolling the skin between the thumb and finger. This helps to assure a uniform fat extraction and determine the end point of surgery. The immediate surrounding areas may be tunneled with the cannula with or without suction on the syringe to help feather the contours and create a smooth transition between treated and untreated zones. The patient may be returned to an upright position to evaluate for symmetry between sides. Once a uniform reduction of the treated area is accomplished, the small nick incisions are closed with a steristrip. The extracted fat is easily collected in an atraumatic fashion in the 10-cc syringe with minimal blood loss and may be used for fat transfer to the central cheeks if a “skeletonized” appearance is present in this region. If necessary, the fat transfer helps blend any discrepancy in soft tissue thickness between cosmetic zones and helps restore a more youthful plump contour to the central cheeks. Ice is applied for 5 to 10 minutes, and the areas are bandaged with pressure to accommodate compression of the treated areas for 24 hours. What Results to Expect The typical volume of extraction for each these areas is minimal, often with only a few milliliters of fat in the aspirate. Most of the reduction noted occurs from subsequent retraction of the skin during the healing process in the weeks to months that follow. Clearly convey to patients in the preoperative consultation that it may take several months for complete resolution of post-operative edema and retraction to produce the appropriate texture and tone of the skin for optimal cosmetic results. Diminution of the treated areas is accomplished with restoration of a younger facial contour (see the photos above). In more than 15 years’ experience with facial microliposuction, we’ve achieved excellent results with very few complications that have been limited to anticipated post-operative edema and bruising. By remaining in the appropriate plane superficial to the SMAS, injury to vessels and nerves should be avoided and haven’t been noted in our practice. While this procedure isn’t technically difficult, the experienced surgeon must learn to accurately match patient expectations to a realistic outcome as an early intervention for facial rejuvenation. Importance of Early Intervention Microliposuction, with or without fat transfer, when the aging process is first becoming a cosmetic concern typically delays the need for more extensive procedures. Skin tone and elasticity are still good, helping to assure a more uniform skin retraction and produce a more successful aesthetic result. Smaller, less intrusive “tune-up” procedures may be undertaken to maintain a youthful appearance and stave off more drastic interventions with more accompanying risks, recovery, and expense. Advantages of the small instruments used include easy stabilization of the syringe with the “power” hand, manual control over induction of negative pressure by withdrawing the plunger of the syringe, and small access points of limited length that tend to heal with near imperceptible scarring hidden within skin lines. The removal of fat and tunneling of the adipose layer produces only a modest reduction of volume. More importantly, they serve to initiate skin retraction.6,7 The elastic nature of the skin allows it to redrape over the improved contour of the underlying supportive soft tissue. Most would agree that predictable, satisfactory results are dependent on evenness of fat extraction from the appropriate plane and small caliber instrumentation with diminished pressures.8-10 Microliposuction is a minimally invasive method that can successfully improve the problematic areas of the meilolabial folds, marionette lines and prominent malar pads.
Exploring Aesthetic Interventions, Part IV:Microliposuction for Treating Perioral Aging
S enescence is an inevitable dynamic process involving alteration in physiology and structure. In the skin, this is most evident in the dermis and underlying supporting structure of the adipose tissue and superficial musculoaponeurotic system (SMAS). Changes of the mature face include alteration of fat deposits. Often there’s a hollowing of the central cheeks, accentuating re-maining fatty deposits of redundant skin folds. This, combined with the cumulative effects of gravity and photodamage, contribute to an aged appearance. As physicians, we’re always seeking the most minimally invasive techniques, especially with patients who are in the early aging process. The trend toward less invasive surgery with decreased risks, less recovery time and less scarring is favored by most surgeons and patients. The Benefits of Liposuction Liposuction has gained favor over many open procedures, allowing for comparable aesthetic re-sults but with limited side effects.1 We’ve found that small instrumentation liposuction (microliposuction) applied to problem perioral areas, such as meilolabial folds and marionette lines and even into adjacent areas such as prominent malar pads, can result in significant aesthetic improvement for patients starting to manifest these changes, which typically become problematic by their late thirties to early fifties. This procedure may be performed under local anesthesia or utilized in combination with more extensive techniques such as laser resurfacing or rhytidectomy, which may require additional sedation. Pre-Operative Evaluation Evaluation of the patient’s perioral area for consideration of liposuction surgery should take into account several important aesthetic considerations. The cervicomental angle should ideally lie between 90 and 110 degrees, and the mandibular border should be well defined and oval to produce the most appealing contour and profile. Neck and jowl liposuction as sole intervention or in combination with other surgical procedures, such as rhytidectomy or platysmaplasty, may be used to address these issues. Reviews for these procedures have been recently published.2-5 Next, the cheek contour, malar fat pads, and meilolabial and marionette lines are evaluated. Often, early atrophic changes of the central cheeks begin to give a sunken appearance, serving as a stark contrast to and accentuating redundant skin folds of the meilolabial folds and marionette lines. The orbicularis oculi muscle relaxes with aging and repositions in an inferolateral direction. In response, the overlying malar fat pads are displaced anteroinferiorly, producing a “sad” appearance of worry and fatigue. If excess adipose tissue is present within these areas, minimally invasive techniques work well to remove the tissue with small instruments, which minimizes scarring and aids healing. The ideal candidate for this intervention displays early signs of aging and possesses good skin tone and elasticity as judged by a snap test — the skin is pinched between the finger and thumb and gently retracted from the face. A quick return to pretest contour portends a more favorable outcome. Delayed return or persistence of tenting of the skin may be an indication that rhytidectomy or another procedure in combination with microliposuction is more appropriate. Pre-operatively, topographic markings delineating the sites to be treated are made with the patient sitting in an upright position because this accentuates the redundancy, ptosis, or prominence of the problem areas. Care is taken to note the location of important underlying structures, notably the branches of the facial nerve. Most at risk is the marginal mandibular branch of the facial nerve as it traverses along the mandibular border. Remaining superficial to the SMAS/platysma at this site is prudent to avoid inadvertent injury to this nerve. Performing the Procedure If microliposuction is to be performed alone, only local anesthesia is necessary. If performed in combination with other surgery, supplemental sedation may be required for the more involved aspects. The patient is placed in a comfortable supine position. Points of entry are anesthetized with 1% lidocaine with 1:100,000 epinephrine. This is performed in the smile lines or lateral nasal ala for meilolabial folds, in the oral commissures for marionette lines, or in the crow’s feet for malar pads. A beveled nick incision with a number 11 blade is made to accommodate passage of a 1.5-mm infusion cannula attached to a 10-cc syringe. Dilute tumescent solution composed of 0.25% lidocaine with 1:250,000 epinephrine (1% lidocaine with 1:1,000,000 epinephrine diluted 1:3) with normal saline and infuse it in the superficial adipose layer to produce sufficient tumescence of the area to be treated. This not only provides the necessary skin turgor to facilitate fat extraction, but also serves to hydrodissect the proper plane for liposuction superficial to the SMAS. A 1.5-mm spatula cannula is then introduced along the same tract with the ports of the cannula facing down. The plunger of the syringe is drawn back to produce a vacuum, and the cannula is advanced in a fanned pattern over the areas to be treated. Make sure that you see fat flowing into the syringe. The “smart” hand may help to guide the cannula by pinching the areas to be suctioned. The process continues with frequent assessment of skin thickness by rolling the skin between the thumb and finger. This helps to assure a uniform fat extraction and determine the end point of surgery. The immediate surrounding areas may be tunneled with the cannula with or without suction on the syringe to help feather the contours and create a smooth transition between treated and untreated zones. The patient may be returned to an upright position to evaluate for symmetry between sides. Once a uniform reduction of the treated area is accomplished, the small nick incisions are closed with a steristrip. The extracted fat is easily collected in an atraumatic fashion in the 10-cc syringe with minimal blood loss and may be used for fat transfer to the central cheeks if a “skeletonized” appearance is present in this region. If necessary, the fat transfer helps blend any discrepancy in soft tissue thickness between cosmetic zones and helps restore a more youthful plump contour to the central cheeks. Ice is applied for 5 to 10 minutes, and the areas are bandaged with pressure to accommodate compression of the treated areas for 24 hours. What Results to Expect The typical volume of extraction for each these areas is minimal, often with only a few milliliters of fat in the aspirate. Most of the reduction noted occurs from subsequent retraction of the skin during the healing process in the weeks to months that follow. Clearly convey to patients in the preoperative consultation that it may take several months for complete resolution of post-operative edema and retraction to produce the appropriate texture and tone of the skin for optimal cosmetic results. Diminution of the treated areas is accomplished with restoration of a younger facial contour (see the photos above). In more than 15 years’ experience with facial microliposuction, we’ve achieved excellent results with very few complications that have been limited to anticipated post-operative edema and bruising. By remaining in the appropriate plane superficial to the SMAS, injury to vessels and nerves should be avoided and haven’t been noted in our practice. While this procedure isn’t technically difficult, the experienced surgeon must learn to accurately match patient expectations to a realistic outcome as an early intervention for facial rejuvenation. Importance of Early Intervention Microliposuction, with or without fat transfer, when the aging process is first becoming a cosmetic concern typically delays the need for more extensive procedures. Skin tone and elasticity are still good, helping to assure a more uniform skin retraction and produce a more successful aesthetic result. Smaller, less intrusive “tune-up” procedures may be undertaken to maintain a youthful appearance and stave off more drastic interventions with more accompanying risks, recovery, and expense. Advantages of the small instruments used include easy stabilization of the syringe with the “power” hand, manual control over induction of negative pressure by withdrawing the plunger of the syringe, and small access points of limited length that tend to heal with near imperceptible scarring hidden within skin lines. The removal of fat and tunneling of the adipose layer produces only a modest reduction of volume. More importantly, they serve to initiate skin retraction.6,7 The elastic nature of the skin allows it to redrape over the improved contour of the underlying supportive soft tissue. Most would agree that predictable, satisfactory results are dependent on evenness of fat extraction from the appropriate plane and small caliber instrumentation with diminished pressures.8-10 Microliposuction is a minimally invasive method that can successfully improve the problematic areas of the meilolabial folds, marionette lines and prominent malar pads.
S enescence is an inevitable dynamic process involving alteration in physiology and structure. In the skin, this is most evident in the dermis and underlying supporting structure of the adipose tissue and superficial musculoaponeurotic system (SMAS). Changes of the mature face include alteration of fat deposits. Often there’s a hollowing of the central cheeks, accentuating re-maining fatty deposits of redundant skin folds. This, combined with the cumulative effects of gravity and photodamage, contribute to an aged appearance. As physicians, we’re always seeking the most minimally invasive techniques, especially with patients who are in the early aging process. The trend toward less invasive surgery with decreased risks, less recovery time and less scarring is favored by most surgeons and patients. The Benefits of Liposuction Liposuction has gained favor over many open procedures, allowing for comparable aesthetic re-sults but with limited side effects.1 We’ve found that small instrumentation liposuction (microliposuction) applied to problem perioral areas, such as meilolabial folds and marionette lines and even into adjacent areas such as prominent malar pads, can result in significant aesthetic improvement for patients starting to manifest these changes, which typically become problematic by their late thirties to early fifties. This procedure may be performed under local anesthesia or utilized in combination with more extensive techniques such as laser resurfacing or rhytidectomy, which may require additional sedation. Pre-Operative Evaluation Evaluation of the patient’s perioral area for consideration of liposuction surgery should take into account several important aesthetic considerations. The cervicomental angle should ideally lie between 90 and 110 degrees, and the mandibular border should be well defined and oval to produce the most appealing contour and profile. Neck and jowl liposuction as sole intervention or in combination with other surgical procedures, such as rhytidectomy or platysmaplasty, may be used to address these issues. Reviews for these procedures have been recently published.2-5 Next, the cheek contour, malar fat pads, and meilolabial and marionette lines are evaluated. Often, early atrophic changes of the central cheeks begin to give a sunken appearance, serving as a stark contrast to and accentuating redundant skin folds of the meilolabial folds and marionette lines. The orbicularis oculi muscle relaxes with aging and repositions in an inferolateral direction. In response, the overlying malar fat pads are displaced anteroinferiorly, producing a “sad” appearance of worry and fatigue. If excess adipose tissue is present within these areas, minimally invasive techniques work well to remove the tissue with small instruments, which minimizes scarring and aids healing. The ideal candidate for this intervention displays early signs of aging and possesses good skin tone and elasticity as judged by a snap test — the skin is pinched between the finger and thumb and gently retracted from the face. A quick return to pretest contour portends a more favorable outcome. Delayed return or persistence of tenting of the skin may be an indication that rhytidectomy or another procedure in combination with microliposuction is more appropriate. Pre-operatively, topographic markings delineating the sites to be treated are made with the patient sitting in an upright position because this accentuates the redundancy, ptosis, or prominence of the problem areas. Care is taken to note the location of important underlying structures, notably the branches of the facial nerve. Most at risk is the marginal mandibular branch of the facial nerve as it traverses along the mandibular border. Remaining superficial to the SMAS/platysma at this site is prudent to avoid inadvertent injury to this nerve. Performing the Procedure If microliposuction is to be performed alone, only local anesthesia is necessary. If performed in combination with other surgery, supplemental sedation may be required for the more involved aspects. The patient is placed in a comfortable supine position. Points of entry are anesthetized with 1% lidocaine with 1:100,000 epinephrine. This is performed in the smile lines or lateral nasal ala for meilolabial folds, in the oral commissures for marionette lines, or in the crow’s feet for malar pads. A beveled nick incision with a number 11 blade is made to accommodate passage of a 1.5-mm infusion cannula attached to a 10-cc syringe. Dilute tumescent solution composed of 0.25% lidocaine with 1:250,000 epinephrine (1% lidocaine with 1:1,000,000 epinephrine diluted 1:3) with normal saline and infuse it in the superficial adipose layer to produce sufficient tumescence of the area to be treated. This not only provides the necessary skin turgor to facilitate fat extraction, but also serves to hydrodissect the proper plane for liposuction superficial to the SMAS. A 1.5-mm spatula cannula is then introduced along the same tract with the ports of the cannula facing down. The plunger of the syringe is drawn back to produce a vacuum, and the cannula is advanced in a fanned pattern over the areas to be treated. Make sure that you see fat flowing into the syringe. The “smart” hand may help to guide the cannula by pinching the areas to be suctioned. The process continues with frequent assessment of skin thickness by rolling the skin between the thumb and finger. This helps to assure a uniform fat extraction and determine the end point of surgery. The immediate surrounding areas may be tunneled with the cannula with or without suction on the syringe to help feather the contours and create a smooth transition between treated and untreated zones. The patient may be returned to an upright position to evaluate for symmetry between sides. Once a uniform reduction of the treated area is accomplished, the small nick incisions are closed with a steristrip. The extracted fat is easily collected in an atraumatic fashion in the 10-cc syringe with minimal blood loss and may be used for fat transfer to the central cheeks if a “skeletonized” appearance is present in this region. If necessary, the fat transfer helps blend any discrepancy in soft tissue thickness between cosmetic zones and helps restore a more youthful plump contour to the central cheeks. Ice is applied for 5 to 10 minutes, and the areas are bandaged with pressure to accommodate compression of the treated areas for 24 hours. What Results to Expect The typical volume of extraction for each these areas is minimal, often with only a few milliliters of fat in the aspirate. Most of the reduction noted occurs from subsequent retraction of the skin during the healing process in the weeks to months that follow. Clearly convey to patients in the preoperative consultation that it may take several months for complete resolution of post-operative edema and retraction to produce the appropriate texture and tone of the skin for optimal cosmetic results. Diminution of the treated areas is accomplished with restoration of a younger facial contour (see the photos above). In more than 15 years’ experience with facial microliposuction, we’ve achieved excellent results with very few complications that have been limited to anticipated post-operative edema and bruising. By remaining in the appropriate plane superficial to the SMAS, injury to vessels and nerves should be avoided and haven’t been noted in our practice. While this procedure isn’t technically difficult, the experienced surgeon must learn to accurately match patient expectations to a realistic outcome as an early intervention for facial rejuvenation. Importance of Early Intervention Microliposuction, with or without fat transfer, when the aging process is first becoming a cosmetic concern typically delays the need for more extensive procedures. Skin tone and elasticity are still good, helping to assure a more uniform skin retraction and produce a more successful aesthetic result. Smaller, less intrusive “tune-up” procedures may be undertaken to maintain a youthful appearance and stave off more drastic interventions with more accompanying risks, recovery, and expense. Advantages of the small instruments used include easy stabilization of the syringe with the “power” hand, manual control over induction of negative pressure by withdrawing the plunger of the syringe, and small access points of limited length that tend to heal with near imperceptible scarring hidden within skin lines. The removal of fat and tunneling of the adipose layer produces only a modest reduction of volume. More importantly, they serve to initiate skin retraction.6,7 The elastic nature of the skin allows it to redrape over the improved contour of the underlying supportive soft tissue. Most would agree that predictable, satisfactory results are dependent on evenness of fat extraction from the appropriate plane and small caliber instrumentation with diminished pressures.8-10 Microliposuction is a minimally invasive method that can successfully improve the problematic areas of the meilolabial folds, marionette lines and prominent malar pads.
