These are areas many cosmetic surgeons decline to treat owing to potential problems yet each is amenable to the microcannula technique. The goal on the upper arms is to remove as much fat as possible yet preserve the immediate subdermal fat plane and avoid trauma to the skin; thus, microcannulas are considered the cannulas of choice because of the need to avoid the immediate subdermal area. Larger cannulas carry the risk of penetrating into undesired regions, rapidly removing fat before the cosmetic surgeon realizes that the cannula is not properly placed, thereby resulting in tracking, dimpling, and puckering. In the properly selected patient, skin contraction on the arms can be substantial and significant contour improvements can result. Incision sites are placed at the elbow and the scapular region. The bulk of lipoaspiration should occur on the posterior aspect of the arm with long strokes using a 12- or 14-gauge cannula. Lillis emphasizes that multiple incision sites with extensive interdigitated cross tunnels results in the desired thorough even fat reduction.
Compression postoperatively is important but the patient should be forewarned that a significant amount of distal edema may occur. Calves and ankles are similarly treated. The challenge in treating these areas is determining if there is fat present and how much needs to be removed. That decision is beyond the purview of this article, leave it be said that sometimes a firm area that clinically appears devoid of fat indeed is suffused with the same. In contrast to liposuction of the arms, the legs are addressed circumferentially, sparing the immediate pretibia. This is a challenging area because the natural contours of the lower extremities are uneven and rounded. The main task to be achieved in this region is even fat removal both from the individual extremity and from the contralateral limb. Again, this makes the microcannula the instrument of choice both in sculpting and in a slow steady fat removal, which reduces the risk of contour defects.
Furthermore, microcannulas allow for feathering with the more superior portion of the tibia. As with the arms, small cannulas, non-aggressive tips, and multiple interdigitating tunnels facilitate a satisfactory low-risk approach. Lillis describes the use of 12- and 14-gauge Klein cannulas or a 2.5-mm standard cannula. The one technical difference in this area is that grasping and pinching can be difficult and is often not necessary as the fat is already compressed and relatively immobile. Postoperative swelling can be problematic and a compression hose and leg elevation are necessary.
Ports are typically left open with the microcannula technique. Significant drainage may occur for up to 72 h and may be blood-tinged. Immediately after the procedure absorbent pads are applied. These may be abdominal pads or even women’s absorbent pads, which are inexpensive and easy to change. A compressive elastic garment is applied which provides support and helps contour the skin during the retraction phase in the time following the liposuction. Heavy compression garments have been found to be unnecessary and possibly counterproductive. Patients generally return to normal function quite quickly with the microcannula technique. The prolonged anesthesia effect of tumescent liposuction confers a comfort previously unknown in liposuction surgery in the immediate postoperative period.
In general, patients prefer a few days rest but not uncommonly return to work within days. We have had patients return to work or go on vacation within a day or two of abdominal liposuction owing to the less traumatic nature of microcannula liposuction with tumescent anesthesia. Skin retraction is a slow process that occurs over weeks. Edema may persist for 2 months or longer and patients must be counseled that the final result may not be apparent for 2 months or longer. Occasional touch-up procedures may be needed but should be delayed at least 2 or 3 months after the initial procedure. Some cosmetic surgeons recommend up to a 6-month delay.
Problems of surface irregularity are significantly reduced with microcannula liposuction. One of the cosmetic surgeons (B.I.R.) was trained initially with “standard” larger cannulas and noticed a reduction in contour problems and irregularities after changing to microcannulas. The risk of intraoperative hemorrhage is quite low with this technique in part owing to cannula size and in part owing to the vasoconstrictive nature of epinephrine when adequate tumescence occurs. There is a low rate of infection with tumescent anesthesia that may be due to the beneficial antibacterial aspect of lidocaine. Scarring is generally minimal with the microcannula technique, although possible pigmentary alteration at the ports may occur. Complications specific to the tumescent technique may result from the large volumes and amounts of lidocaine infiltrated. Edema and ecchymoses may result and may be especially noticeable in dependent areas. Liposuction safety has been an issue since a 1999 article reporting five deaths in patients undergoing a form of tumescent anesthesia. However, when liposuction has been performed by pure tumescent anesthesia in the conscious patient, there have been no recorded deaths. Moreover, studies of tumescent liposuction under local anesthesia on large numbers of patients have identified an extremely low rate of any serious adverse event.
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