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system (SMAS). The first step is to achieve a superficial,
cephalad cervical plexus block, aiming for the lesser
occipital nerve, great auricular nerve and transverse
cervical nerve rather than the inferiorly running nerves
of the punctum nervosum. An aliquot of 3% lidocaine
(one 1.8 mL carpule) with norepinephrine (1:100,000)
is placed at the punctum nervosum, which is located at
the posterior aspect of the sternocleidomastoid (SCM)
muscle, midway between the mastoid process and the
transverse process of C6 [Figure 2]. The second step is to a b
infiltrate the periauricular incision line using 2 carpules Figure 1: Effect of gravity (position) on the facial soft tissues of an
of lidocaine and a serial puncture technique. The third 86‑year‑old man in upright (a) and prone (b) positions; the photo in
step involves the infiltration of the dissection area using (b) was rotated 90° for comparison with the photo in (a) to shows the
effects of gravity on the midface, revealing that the aged appearance
a Whitacre epidural cannula and the super wet technique results not only from fat atrophy but also from gravity
with a modified Klein solution consisting of one 20 mL
vial of lidocaine (2%) with epinephrine (1:100,000) and
two vials of 0.9% sodium chloride (normal saline).
[15]
The 25‑gauge 3.5 inch Whitacre spinal needle (Becton,
Dickinson and Company, NJ, USA) has a pencil tip and
lateral opening, which spreads the subcutaneous tissues
without cutting nerves and vessels. With a little pressure,
it is inserted into the area infiltrated in step 2. The area
can then be anesthetized painlessly by slowly sliding
the cannula in the subcutaneous fat plane, continuously
delivering the small amounts of the anesthetic
solution [Video 1].
Whereas the tumescent technique uses a large volume
of dilute solution to stretch the skin taut, the super wet
technique injects less than half the volume required for
the tumescent technique, 40 mL suffices to infiltrate both
sides. Figure 2: Punctum nervosum with the branches. A: lesser occipital nerve;
B: great auricular nerve; and C: transverse cervical nerve
MICRO‑LIPOSUCTION

As we age, the loss of fibrous support, endocrine changes,
a sedentary life style and excess caloric intake result in fat
pockets in the cheek and the anterior neck becoming more
voluminous and delineated. Disruption of the jaw line by
jowling is often the first sign that leads patients to consider
a cosmetic procedure, and submental lipodystrophy is
hereditary in some individuals. Because a skin‑only facelift
cannot alter these signs of aging, submental liposuction
is carried out prior to the lateral work, requiring another
20 mL of simplified Klein solution. Central lipodystrophy Figure 3: A 2.7 mm Becker grater round cannula with multiple
is accessed by a 2‑mm incision with a number 11 blade perforations (1 mm diameter)
anterior to the submental crease. A Becker grater round
cannula (2.7 mm diameter, Wells Johnson Company, Tucson, Surgical removal of the jowl fat is essential for the lifting
AZ, USA) [Figure 3] is connected to a 10 mL disposable procedure. This may be performed by Metzenbaum
syringe with a luer lock and introduced without suction scissors or by open liposuction with a Becker grater
to dissect the subcutaneous plane at the supraplatysmal cannula, after elevating the skin flap [Figure 4]. However,
level. It is easy to inadvertently enter the subplatysmal closed liposuction through a 2‑mm stab incision anterior
plane, leading to disruption of the capsule of the to the earlobe can be used to avoid irregularities,
submandibular gland with subsequent ptosis or injury to hematomas and damage to the marginal branch of cranial
the marginal branch of the facial nerve. After determining nerve VII. Counter pressure is important, but also leaving
the appropriate plane, the syringe plunger is withdrawn a layer of fat on the undersurface of the dermis [Video 3].
to create a 2‑mL space. Just posterior to the central stab
incision, a cannula with an open tip is used to maintain BAKER SMASECTOMY
negative pressure in the syringe, with the tip close to the
exit site. Rapid movements are required [Video 2]. Traction on low suspension sutures provides a strong

302 Plast Aesthet Res || Vol 2 || Issue 6 || Nov 12, 2015