Topical regimens and oral medications have remained the conservative approach to treat axillary hyperhidrosis and are effective for many patients. Newer surgical approaches have been described, including treatment with Botox, which has been approved by the FDA for this purpose. The results with all of these treatment modalities, however, are often transient. Microcannula liposuction is a minimally invasive and low-risk modality with the potential for a reasonable permanent clinical remission of this significant lifestyle and quality-of-life issue. The starch iodine test defines the involved area. The area of hyperhidrosis is not always defined specifically by the hair distribution; it may occur in only a small area or may be present in the entire axilla. After being prepped in a sterile fashion, the involved areas can be treated. Only a few distant incision sites are needed at the periphery of the hyperhidrotic area placed closely enough to allow the normal interdigitation and crisscrossing of the microcannula technique. Because of the small volume of tumescent fluid and the limited area, a higher lidocaine concentration such as 0.1 or 0.15% may be chosen.
In this region, the anesthesia is infused superficially and in contrast to liposuction in other areas, the peau d’orange skin effect is the desired end point. Waiting 15–30 min after infiltration is needed for maximum anesthetic and vasoconstrictive effect. Anatomically, the sweat glands are found at the base of the dermis and in the most superficial levels of the fat. Therefore, liposuction here is performed very superficially and, as such, can only be accomplished with a microcannula. Any larger cannula would be tissue-destructive and counterproductive. Swinehart recommends the 12-gauge Finesse cannula (apertures only on one side of the tubing) but keeps the aperture directed upward adjacent to the dermis in contrast to the normal technique of directing the apertures downward. Because of the slight curve of the cannula tip, the apertures do not directly contact the dermis when using this cannula as long as the cosmetic surgeon is careful.
Two or three crisscrossed patterns are initially performed. Swinehart then advocates using the Capistrano cannula with circumferential apertures to rasp lightly against the dermis and remove or destroy sweat glands. The ultimate goal is removal of eccrine sweat glands and not fat, reflecting the superficial nature of the procedure. Multiple tunnels with conservative liposuction being performed in multiple directions are required. Care must be taken to avoid leaving a large area of dermis unsupported by vascular structures. It is preferable to return for a second procedure rather than risk developing substantial necrosis of the dermis. Patients are warned that final results may take months.
Senescence may cause hollowing of the central cheeks with accentuation of remaining fat in the nasolabial folds. Correction of these irregularities may contribute to a more refined, pleasant facial contour but these areas can only be addressed with microcannulas. Often, the amounts to be removed are so small that syringe-assisted lipoaspiration is effective. Areas that can be aspirated include the malar fat pads, meilolabial folds, marionette lines, and jowls. Ideal candidates for facial liposculpture demonstrate early aging with good elasticity and skin tone. This can be tested with the snap test, in which the skin is pinched and retracted and then returns quickly to normal contour. Preoperative markings should be made with the patient in the sitting position. The most important underlying structure of which the cosmetic surgeon must always be aware is the marginal mandibular branch of the facial nerve as it traverses the mandible. Remaining in the superficial plane while aspirating in this area is mandatory. Tumescent anesthesia is infiltrated using a 0.1–0.15% lidocaine concentration.
The syringe- and-needle method may be chosen for infiltration rather than an infusion pump. Proper tumescent infiltration will magnify the tissue but not distort tissue landmarks. This concept should help cosmetic surgeons decide on the appropriate infiltration end point. Aspiration ports are carefully selected to be hidden in the lateral nasal ala, oral commissures, smile lines, or crow’s feet. In this procedure, the superficial fat compartment is the target treatment zone. The cosmetic surgeons prefer utilizing a 16-, 18-, or 20-gauge Finesse-style cannula that may be connected directly to a syringe or fine tubing attached to vacuum suction. One hand should grasp and pinch the areas to be suctioned, while the dominant hand is used to pass the cannula parallel to the direction of the fold being aspirated. Frequent assessment is required because only minute amounts of fat need be extracted and feathering of adjacent areas is important.
Rolling the skin between the fingers allows for assessment of the tissue fat aspirated. This procedure is primarily a superficial liposuction of a very small fat compartment and, as such, the smallest effective microcannula should be chosen. It is not necessary to rotate through cannula sizes as may be done for other compartments such as the abdomen. Furthermore, use of only a few aspiration ports may be all that is required on the cheeks, jowls, or malar fat pads. The use of multiple crisscrossing interdigitated tunnels is not as necessary as in other areas. Finally, this procedure should be performed in a conscious patient in the sitting position for more accurate endpoint determination. The end result is dependent on skin retraction over the site, so only a modest volume reduction needs to be attained. Aspirated fat should then be considered for fat transfer into adjacent atrophic areas.
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1. Born With Imperfections; Cosmetology offers to undo them perfectly!
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