Section 4 Plastic and Reconstructive Problems

Holcomb

immediately subcutaneous fatty tissue adherent to the undersurface of the skin by using the lipoas- piration cannula with the ports directed upward to- ward the undersurface of the dermis. Generally a yellow or orange emulsion of subcutaneous fatty tissue is obtained. Depending on the volume of lip- oaspirate, a second syringe may be needed to complete the procedure. The lipoaspiration portion of the procedure concludes when the desired tissue contour is achieved or when the emulsified fat aspirate return wanes or becomes blood tinged. Persistent dermal to platysma fibrous attach- ments may represent a potential limiting factor with regard to the ability of the neck skin to adequately contract. After the lipoaspirate is ob- tained, the cannula is used in a sweeping motion to manually avulse any remaining fibrous attach- ments that may limit appropriate repositioning of the skin. Occasionally it may be necessary to tran- sition the percutaneous LANC procedure to an open LANC procedure. If significant submental fullness is still evident, then a submental incision may be needed for direct evaluation for platysma muscle laxity and ptosis, bulky fat adherent to un- dersurface of the skin flap, and excess subplatys- mal fatty tissue—if present, these findings are addressed surgically. Immediately after treatment, a compression dressing is applied in a similar manner as for post-LAFC with a layer or 2 of thick cotton and a compression garment. The wound is evaluated the next day and the cotton is removed, but pa- tients are encouraged to wear the compression garment as much as possible for at least 1 week af- ter treatment. Patient expectations must be care- fully managed during the recovery and extended post-treatment period, as described previously. Fig. 5 shows interim results (3 months) in a patient with substantial submental fullness and skin laxity. Adjunctive use of the thermally confined micro- pulsed 1444-nm Nd:YAG interstitial fiber laser during face and neck lift surgery involves incorpo- ration of the LAFC and LANC procedures where indicated with additional use of the laser for devel- opment of skin flaps and for lysis of osseocutane- ous anchoring ligaments in the mid- and lower face. It should be appreciated that the jowl may encompass a significant volume of tissue above and below (with aging) the caudal margin of the mandible and that the jowl position may change significantly with patient positioning for facial INTERSTITIAL ND:YAG FIBER LASER– ASSISTED FACE AND NECK LIFT—TREATMENT METHOD

tissue while actively lasing during LANC—this facilitates even distribution of laser energy and limits the potential for clinical thermal confinement failure. Some latitude exists with regard to energy delivery and treatment parameters but the author suggests that surgeons proceed with caution with energy delivery totals exceeding 1000 J dur- ing LANC with these settings. At higher total en- ergy delivery settings, the neck skin may become slightly to noticeably warm. Immediately after energy delivery, a similar volume (eg, 12 mL) of room temperature sterile saline is infiltrated into the treatment area. Removal of emulsified tissue and liquefied fat via manual lipoaspiration with a 2.1-mm offset triple port aspiration cannula (Tulip) and a 12-mL syringe (prefilled with 1-mL sterile saline) enables definitive tissue contouring. Fig. 4 depicts the full minimal instrumentation requirement for LANC. Use of the Tulip Snap Lok facilitates efficient lip- oaspiration while allowing a surgeon to focus on tissue contouring. As with performing LAFC, the aspiration cannula may well become blocked during lipoaspiration, so the blockage must be cleared, as discussed previously, and the proce- dure continued. If the syringe becomes filled with air, then the same remedies can be applied as described previously, taking care not to expel any fat already aspirated at this point. At the end of the lipoaspiration, the fat aspirate volume (less 1.0 mL from sterile saline prefilling) is recorded in the treatment record. Initially, the aspiration cannula should be more superficial (immediately subcutaneous) with the ports directed down. Effective debulking in areas of maximal subcutaneous tissue thickness, how- ever, generally requires guiding the cannula into these areas at a deeper level. Using a gentle tech- nique, it is helpful to remove some of the

Fig. 4. LANC instrumentation. ( Top ) 1.6-mm Tulip mul- tihole infiltration cannula attached to 12-mL syringe containing local anesthetic solution. ( Middle ) 60- m m Bare laser fiber with red diode aiming beam visible ( left ) and 18-gauge needle ( right ). ( Bottom ) 2.1-mm Tulip triple port (ports offset or nonaxial with only 1 port showing) aspiration cannula attached to 12-mL syringe prefilled with 1.0-mL sterile saline (Tulip Snap Lok not shown).