Submental suction-assisted lipectomy without platysmaplasty: pushing the (skin) envelope to avoid a face lift for unsuitable candidates

Patients with submental fullness may not be candidates for a full or short-scar face lift because of medical contraindications, uncontrolled hypertension, a refractory nicotine habit, or anticoagulant medications, or patients may disqualify themselves because of cost, unavailable recovery time, or emotional resistance. Submental suction-assisted lipectomy has traditionally been reserved for younger patients. For older patients, suction-assisted lipectomy is typically used as an adjunct for face/neck lifts. This report describes experiences with suction-assisted lipectomy for older patients who were not face lift candidates, for the aforementioned reasons. The study goals were to better delineate the indications for submental suction-assisted lipectomy, as opposed to a face lift, and to obtain improved results with a less-invasive procedure. A 6-year study involving 132 patients (21 to 73 years of age), of whom 4.5 percent were men, was performed. Eighty-eight patients (67 percent), the primary focus of this study, were more than 40 years of age. Of those 88 patients, 24 patients (18 percent of the 132 patients in this series) were in their forties, 45 (34 percent) were in their fifties, 16 (12 percent) were in their sixties, and three (2.3 percent) were at least 70 years of age. The median follow-up time in this series was more than 1 year. The results were assessed with the five criteria for facial rejuvenation described by Ellenbogen and Karlin. All patients demonstrated improvement, with three to five of the Ellenbogen-Karlin neck rejuvenation criteria being met for each patient. All patients demonstrated an improved submandibular border, a more visible anterior sternocleidomastoid muscle border, and an improved neck angle (as determined with angle measurements). For many patients, all five of the Ellenbogen-Karlin criteria were met. A visible subhyoid depression and a visible thyroid cartilage bulge were the two criteria most often not met. A retrospective evaluation using Baker's preoperative classification of patient types for short-scar face lifts was performed. Results for patients more than 64 years of age (11 patients) were less satisfactory, often with redundant or crepe paper-like skin. Submental suction-assisted lipectomy, as opposed to a face lift, was observed to be a reasonable alternative for older patients who were unable or unwilling to undergo a face lift. Localized fullness in the midline was observed to be the best predictor of a good outcome (even better than age or skin tone). A crepe paper appearance of the skin preoperatively was the best predictor of failure. The surgical anatomical features, technique, advantages, disadvantages, and principles are discussed. Complications and their treatment are addressed. It is concluded that submental suction-assisted lipectomy alone, without platysmaplasty, can be helpful for patients with submental fullness who are unsuitable candidates for a face lift and who accept the limitations of liposuction without platysmaplasty. Suction-assisted lipectomy can sufficiently contract and smooth the skin envelope for selected patients, with less consideration for age than previously proposed.     

Suction-assisted lipectomy for correction of 202 figure faults in 101 patients: indications, limitations, and applications

Since its introduction in the United States, suction-assisted lipectomy has proven to be a safe, effective technique for correction of figure faults. It has been greeted with considerable skepticism by many practitioners, however, owing to the poor results many have obtained in their initial attempts to apply similar techniques. Suction lipectomy using the blunt technique is a safe procedure that can yield consistently good results when appropriately applied. It is suggested that the principal reason others have had difficulty involves problems in patient selection. The technique may not be effective for the correction of generalized obesity and cannot be expected to dramatically alter overall appearance. Patients should be selected for treatment of specific "figure faults" and educated as to what may realistically be expected. The patient's emotional and psychological condition must be taken into consideration. We report a series of 101 patients treated with a total of 202 separate suction lipectomy procedures with good results and only two minor complications. A survey of patients treated by the method reveals a generally high level of satisfaction and some of the ambivalence that might be anticipated from such a technique.     

The trauma of suction-assisted lipectomy cannula on flap circulation in rats.

The effect of suction-assisted lipectomy on cutaneous blood vessels of inguinal skin flaps was studied and compared in 191 rats. Different types of cannula tips were used; the number of passes was standardized. In one experiment, following suctioning, 3 X 2 cm groin island flaps based on inferior epigastric pedicles were raised and then reattached. Fluorescein dye study and microangiography were performed to evaluate flap viability. Flap survival was determined clinically and by histologic examination on the fifth postoperative day. Three-sided inguinal random-pattern flaps were raised in a second experiment and reattached following suctioning. On the fifth postoperative day, surviving flap areas were measured using standard photographs and an imaging computer and were compared with controls. Results showed that cannula passes accompanied by vacuum are harmful to vessels, while those unaccompanied by vacuum are not. The greater the number of suctioning passes, the more trauma there is to vessels and the greater is the likelihood of flap necrosis. Conical and spatula tips were more harmful to vessels than spherical, cobra, keel cobra, or Fournier tips. These results support the conclusion that suction-assisted lipectomy enhances the possibility of skin necrosis by traumatizing the vascular pedicle of a flap, especially when it is used as an adjunct to flap elevation.     

Face and neck suction-assisted lipectomy associated with rhytidectomy

A technique is described in which suction-assisted lipectomy is used for excessive fat removal in association with the standard rhytidectomy. It is safe, reliable, and can be performed through a small horizontal submental incision. A more natural appearing neck is produced by adjusting the amount of fat removed. Areas previously considered dangerous for excision because of possible damage to branches of the facial nerves, such as the cheek areas, jowls, parotid, and nasolabial folds, can now be approached.     

Maximizing the use of the abdominoplasty incision

Candidates for abdominoplasty often request multiple procedures at the time of consultation. Some of these patients have the potential opportunity to have ancillary procedures performed through the abdominoplasty incision, such as breast augmentation or suction-assisted lipectomy. Access via the abdominoplasty incision can also limit the need for distant donor sites, for instance, when autologous fillers or rib graft are necessary. The techniques described are straightforward and are based on standard principles that should be considered when ancillary procedures are performed in conjunction with abdominal contouring procedures. In a review of 70 consecutive patients undergoing abdominoplasty, 91 ancillary procedures were performed in conjunction with the abdominoplasty. Of the total number of patients undergoing abdominoplasty, 29 patients underwent 30 procedures facilitated through their abdominoplasty incision, including 23 suction-assisted lipectomies of the flanks, six breast augmentations, and one rib cartilage harvesting for rhinoplasty. A review of the author's experience and discussion for potential options afforded by this exposure are presented.     

Abdominoplasty and abdominal wall rehabilitation: a comprehensive approach

Standard abdominoplasty techniques involve a low horizontal or W skin excision, muscle plication, and umbilical transposition. Newer techniques include suction-assisted lipectomy, the use of high lateral tension with fascial suspension, and external oblique muscle advancement. The author has modified these traditional procedures and added new techniques to improve the aesthetic and functional results of the abdominoplasty procedure. This modification provides a comprehensive approach to abdominal wall aesthetic improvement and rehabilitation. The comprehensive approach described includes four components: the "U-M dermolipectomy," "V umbilicoplasty," the rectus abdominis "myofascial release," and suction-assisted lipectomy. The patient is marked while standing for areas of suction lipectomy and undermining. The lower incision is designed as an open U with the lateral limbs placed inside the bikini line. The upper incision is a lazy M with the higher peaks located at the level of the flanks. Subcutaneous hydration is achieved to perform suction along the flanks, waistline, and iliac areas. Gentle suction of the flaps is also performed. The umbilicus is cored out in a heart shape. The flaps within the U-M marks are excised, and the undermining is performed to the xiphoid and costal margins. The rectus diastasis is marked, and the anterior rectus fascia is incised at the junction of the medial third with the central third of the width of the rectus sheath. Horizontal figure-eight plication sutures by using the lateral fascial edge enable easier infolding of the central tissue. The new recipient of the umbilicus is made by an incision in a V shape on the abdominal flap. The umbilicus is telescoped, and the triangular flap of the abdomen is sutured to the triangular defect of the umbilicus. Skin flap fixation to the umbilicus relieves tension in the lower portion of the flap. The upper skin flap, which is cut in an M manner, provides lateral tension and matches the length of the lower flap. A standard fascial suspension is used and closure is performed in layers. The techniques described here are intertwined procedures. Each facilitates the accomplishment of the other procedure, and they complement each other. They all attain the 12 objectives of the abdominoplasty described. These combined techniques have been used in 104 patients in a period of 11 years. Complications were minimal and easily manageable, except for one patient who required excision of a pseudobursa and retightening of the lower quadrants of the abdominal wall musculature to correct extreme lordosis. A comprehensive approach for the treatment of complex abdominal wall aesthetic and functional defects is presented. These require thoughtful integration of the four components mentioned. This approach has allowed predictable, reproducible, and aesthetically pleasing results.     

Periareolar approach for the correction of congenital symmastia

This report elucidates the continued and relatively rare problem of congenital symmastia and its surgical repair without concomitant bilateral breast reduction. This case highlights the use of suction-assisted lipectomy techniques to address the excess fat in the presternal web and a periareolar approach for access to the intermammary space. The periareolar incision allows for the use of a concealed approach and the avoidance of a central scar that could result in hypertrophy or keloid formation, especially in this patient who is more prone to hypertrophic scarring. Furthermore, plication of the central web dermis to the sternal periosteum in a more superior position serves to not only correct the symmastia but also redrape the excess skin and restore the blunted inframammary folds.     

Plasma lidocaine levels during augmentation mammaplasty and suction-assisted lipectomy

Many plastic surgical procedures are dependent on or aided by the use of local anesthetics. Drug toxicity, although uncommon, is the most feared complication of this technique. There are multiple factors that lead to varying drug levels. These include drug concentration, speed of injection, rate of degradation, total dosage, site of injection or application, rate of administration, and the adjunctive use of vasoconstrictors. This study evaluates the use of subcutaneously injected lidocaine in patients undergoing suction-assisted lipectomy and augmentation mammaplasty. Lidocaine in the concentration of 0.5% containing either 1:100,000 or 1:200,000 epinephrine was used in doses up to 500 mg. Serial lidocaine levels were then obtained up to 1 1/2 hours after injection utilizing two different assay techniques. Our findings demonstrate consistently nondectable serum lidocaine levels despite the use of doses in excess of recommended "safe" amounts. This suggests that under specific circumstances and with certain operative procedures, lidocaine dosing can be liberalized.     

Belt lipectomy for circumferential truncal excess: the University of Iowa experience

When some patients with circumferential truncal excess undergo traditional abdominoplasty, the trunk is not addressed as a unit. Belt lipectomy, a procedure that combines abdominoplasty with circumferential excision of skin and fat, is often more ideal for these patients. In this article, the authors review the literature on belt lipectomy and evaluate their series of 32 patients who underwent belt lipectomy at the University of Iowa. The evolution and current preoperative markings, intraoperative surgical technique, and postoperative care are described. The patients' charts and their preoperative and postoperative photographs were examined retrospectively. It was found that belt lipectomy improved abdominal contour, abdominal wall laxity, mons pubis ptosis, back rolls, waist contour, and buttocks contour. Initially, the procedure was performed on post-weight-reduction patients only, but its indications were extended to three other groups: patients who were 30 to 50 pounds overweight, patients of normal weight who desired a significant overall truncal improvement, and an obese patient with persistent intraabdominal excess. The improvements were significant in all groups of patients except for the latter patient. Complications included a 37.5 percent seroma rate, a 9.3 percent pulmonary embolus rate, and one dehiscence that required reoperation. The authors concluded that belt lipectomy should be seriously considered for patients who present with circumferential truncal excess and for a select group of normal-weight patients. It is not recommended for the obese patient with excessive intraabdominal content. Furthermore, belt lipectomy should be undertaken only in patients who are well informed about the possible risks and complications.     

Comparative study of survival of autologous adipose tissue taken and transplanted by different techniques

In recent years, adipocytes obtained by suction-assisted lipectomy have been used for implantation by injection methods. This study is designed to assess the appearance of suctioned and excised adipose tissue and its survival after being injected or implanted into different tissues (0.5 cc into the rectus muscle and 0.5 cc into the dorsal ear skin) of New Zealand White rabbits. The results showed that significant numbers of adipocytes were ruptured after suction procedures. The intact cells represented approximately 10 percent of the fat cell population. Fat cells in aspirated and excised samples remained intact and did not differ histologically. After being injected into tissue, adipocytes appeared to survive better for a short term in a more vascularized bed (rectus muscle) than in a low vascular area (ear dermis). Long-term studies at 6- to 9-month intervals revealed transplanted adipose tissue, taken by suction or excision, being replaced with fibrosis, although cystic spaces and only a small number of surviving adipocytes were still present. Insulin did not show any protective effects on survival of the adipocytes during their transplantation.     

The effect of epinephrine on blood loss during suction lipectomy

In a prospective, double-blind, controlled study on 26 consecutive patients who underwent suction lipectomy, the injection of epinephrine (1:250,000, 1:500,000, or 1:1,000,000) was not found to decrease fluid/blood loss when compared with saline injection or no injection at all. Since our study fails to support the use of epinephrine to lessen fluid/blood loss during suction lipectomy, we have abandoned its use in that procedure.     

The effect of interleukin-8 on the viability of injected adipose tissue in nude mice

Adipose tissue injection as a free graft for the correction of soft-tissue defects is a widespread procedure in plastic surgery. The main problem in achieving long-term soft-tissue augmentation is partial absorption of the injected fat and hence the need for overcorrection and re-injection. The purpose of this study was to improve the viability of the injected fat by the use of interleukin-8. The rationale for the use of interleukin-8 was its abilities to accelerate angiogenesis and attract inflammatory cells and fibroblasts, providing the injected adipocytes more feeding vessels and a well-established graft bed to enhance their viability. Human adipose tissue, obtained by suction-assisted lipectomy, was re-injected into the subcutis in the scalp of nude mice. Interleukin-8 (0.25 ng) was injected subcutaneously to the scalp as a preparation of the recipient site 24 hours before the fat injection and was added to the fat graft itself (25 ng per 1 cc of injected fat). In the control group, pure fat without interleukin-8 was injected and no interleukin-8 was added for the preparation of the recipient site. One cubic centimeter of fat was injected in each animal in both the study and control groups. There were 10 animals in each group. The animals were euthanized 15 weeks after the procedure. Graft weight and volume were measured and histologic evaluation was performed. In addition, triglyceride content and adipose cell sizes were measured as parameters for fat cells viability. Histologic analysis demonstrated significantly less cyst formation in the group treated with interleukin-8. No significant differences were found between the groups with regard to graft weight and volume or the other histologic parameters investigated. No significant differences were demonstrated in adipose cell sizes and their triglyceride content. In conclusion, less cyst formation, indicating improved quality of the injected fat, can be obtained by the addition of interleukin-8. Further studies of various dosages of interleukin-8 and their long-term effect are required before these encouraging results could be applied clinically.     

A new device to avoid unfavorable results in suction lipectomy

A cannula system with guard wheel attachment and special wrench has been developed and used for suction lipectomy. The devices facilitate the procedure, and results are more consistent and dependable.     

Evaluation of a technique designed to correct nasolabial folds.

This is a long-term follow-up of correction of nasolabial folds in conjunction with face lift that was first published in 1987. In the last 200 face lifts, nasolabial lipectomy has been carried out in 90 percent. Refinements and extensions of the procedure are also described with case illustrations.     

Quantitative analysis of blood and fat in suction lipectomy aspirates

This study of suction lipectomy aspirates from 15 consecutive patients was undertaken to biochemically quantitate the blood-to-fat ratios of the aspirates. A wide variation in the blood-to-fat ratios (8 to 54 percent) was noted, but the authors failed to demonstrate any relationship between the blood-to-fat ratios and the suction lipectomy operative site. Prophylactic measures to allow treatment of patients in a consistently safe manner include carefully screening of patients to exclude those with bleeding disorders or significant illnesses, perioperative oral iron therapy, infiltrating the operation site with a dilute epinephrine solution, hydrating the patients adequately perioperatively, using smaller-diameter cannulas for the aspiration, minimizing aspiration once the aspirate turns grossly bloody, and limiting the aspirate to a volume of less than 1750 ml for any operative procedure.     

Toxic shock syndrome after suction lipectomy

We present a case of toxic shock syndrome with necrotizing fasciitis after suction lipectomy. The patient underwent aesthetic suction lipectomy of the abdomen, buttocks, and thighs during an office procedure by a cosmetic surgeon. On postoperative day 2, the patient was referred to the emergency department of our hospital because of pain. On admission, the patient was in toxic shock. She required intensive medical treatment for about 1 month, along with psychiatric help to adapt after the illness. Although toxic shock syndrome is a rare postoperative complication, every plastic surgeon should be acquainted with it. A combination of early recognition, diagnosis, and aggressive supportive therapy is the only successful treatment.     

Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction

Gynecomastia, or excessive male breast development, has an incidence of 32 to 65 percent in the male population. This condition has important physical and psychological impacts. Advances in elucidating the pathophysiology of gynecomastia have been made, though understanding remains limited. Recommendations for evaluation and workup have varied and are often arbitrary. A diagnostic algorithm is suggested, with emphasis on a comprehensive history, physical examination, and minimizing unnecessary diagnostic testing. Medical management has had limited success; surgical therapy, primarily through excisional techniques, has been the accepted standard. Although effective, excisional techniques subject patients to large, visible scars. Ultrasound-assisted liposuction has recently emerged as a safe and effective method for the treatment of gynecomastia. It is particularly efficient in the removal of the dense, fibrous male breast tissue while offering advantages in minimal external scarring. A new system of classification and graduated treatment is proposed, based on glandular versus fibrous hypertrophy and degree of breast ptosis (skin excess). The authors' series of 61 patients with gynecomastia from 1987 to 2000 at the University of Texas Southwestern Department of Plastic Surgery demonstrated an overall success rate of 86.9 percent using suction-assisted lipectomy (1987 to 1997) and ultrasound-assisted liposuction (1997 to 2000). The authors have found ultrasound-assisted liposuction to be effective in treating most grades of gynecomastia. Excisional techniques are reserved for severe gynecomastia with significant skin excess after attempted ultrasound-assisted liposuction.     

Blood loss in major liposuction procedures: a comparison study using suction-assisted versus ultrasonically assisted lipoplasty.

The blood loss that accompanies liposuction procedures has always been a concern. Tumescent injection of the targeted area of liposuction with dilute lidocaine and epinephrine solution has minimized intraoperative blood loss. Proponents of a newer ultrasonically assisted lipoplasty technique have claimed many benefits over traditional suction-assisted lipoplasty. However, few quantitative data are available on the intraoperative blood loss and the significance of postoperative anemia using the ultrasonic method. A prospective clinical observational design was used to investigate 38 patients undergoing suction-assisted lipoplasty and 37 patients undergoing ultrasound-assisted lipoplasty in whom the liposuction aspirate was expected to be more than 1000 ml. These patients were investigated with preoperative measurement of hemoglobin, platelet count, prothrombin time, partial thromboplastin time, and postoperative measurement of hemoglobin on the seventh postoperative day. In addition, hemoglobin concentration and whole blood volume were calculated from the infranatant portion of the liposuction aspirate. The mean +/- SD volume of the liposuction aspirate was 2901 +/- 1471 ml for suction-assisted compared with 2741 +/- 1086 ml for ultrasound-assisted lipoplasty. The mean +/- SD of whole blood volume in liposuction aspirate per case was 36 +/- 50.82 ml for suction-assisted lipoplasty and 36 +/- 28.62 ml for ultrasound-assisted lipoplasty. The mean +/- SD of the preoperative hemoglobin concentration was 13.93 +/- 0.99 g/dl for suction-assisted lipoplasty and 14.05 +/- 1.16 g/dl for ultrasound-assisted lipoplasty, whereas the mean +/- SD of the postoperative hemoglobin concentration was 13 +/- 1.42 g/dl for suction-assisted lipoplasty and 13.05 +/- 1.32 g/dl for ultrasound-assisted lipoplasty. The mean decrease in hemoglobin on the seventh postoperative day was 0.93 +/- 0.92 g/dl for suction-assisted lipoplasty and 1 +/- 0.64 g/dl for ultrasound-assisted lipoplasty. The volume of whole blood loss was estimated to be 12.4 ml in each 1000 ml of liposuction aspirate when using suction-assisted lipoplasty versus 13.1 ml when using ultrasound-assisted lipoplasty. All procedures were done under general anesthesia, and patients were discharged home on the same day. No blood transfusion was required. This study shows that blood loss using the ultrasonic technique is slightly higher, though insignificant, than when using suction. However, this study did not demonstrate a difference in the postoperative hemoglobin decrease between the two techniques.     

Effect of liposuction on skin perfusion

Clinical reports of full-thickness skin necrosis have raised concern about the thermal and dermal ischemic effects of ultrasound-assisted liposuction. The purpose of this study was to evaluate skin perfusion in patients treated with ultrasound-assisted liposuction or suction-assisted liposuction. Patients (n = 75) were studied prospectively in the perioperative period surrounding their suction-assisted liposuction (31 patients) or ultrasound-assisted liposuction (64 patients). The laser Doppler flowmeter was used to monitor skin perfusion in the treated regions preoperatively, intraoperatively, and postoperatively at a series of time intervals. The effects of the anesthetic, wetting solution, and type of liposuction (suction-assisted liposuction or ultrasound-assisted liposuction) on skin perfusion were measured. Anesthetic induction significantly increased measured skin perfusion. Wetting solution infusion significantly decreased skin perfusion (-57.4 percent +/- 2.0) by 15 minutes postinfusion. Skin perfusion in the ultrasound-assisted liposuction group was significantly greater than that of the suction-assisted liposuction patients at 1 hour, 1 day, and 1 week postoperatively; however, by 2 to 5 weeks, no difference in skin perfusion was noted and skin perfusion had returned to preoperative levels in both groups. Although skin perfusion in the suction-assisted liposuction group was significantly lower than in the ultrasound-assisted liposuction group in the early postoperative period, no differences in skin perfusion between the groups were noted beyond 1 week postoperatively, suggesting that neither technique impairs perfusion.     

Computerized suction lipectomy aspirator monitor for improved results in suction lipectomy

A new computerized suction aspirator monitor is described. This device offers the benefits of instantaneous and concurrent scientifically accurate readout of aspirate contents in five separate bodily areas. Thus knowledge of amounts of blood versus fat can be immediately known without resorting to guess, estimate, or cumbersome lipocrit determination by centrifuging. Advantages of such a device include better accuracy in determination of fat removal from each area, with improvement of symmetrical fat removal. More exact determination of blood loss with improved hemodynamic replacement is also more easily and safely accomplished. In an area of mystique, experience, artistry, and aesthetic appreciation which has cloaked the initial enthusiasm for suction lipectomy, a new generation of scientific accuracy is now possible. Thus accurate determination of aspirate content vis-a-vis fat and blood can now transform this procedure into a more sophisticated and scientifically accurate operation which traditionally is desired by most practitioners of suction lipectomy.