Tunnelization

After liposuction itself or when creating small tunnels with a cannula without suction, we start tunnel-ization with nontraumatic instruments with progressive width, specially developed for this purpose (Fig. 39.5). These instruments are introduced one by one - first the thinnest one (Fig. 39.6) and then progressively a wider one (Fig. 39.7) until the widest one

Fig. 39.5. Surgical instruments specially developed to perform rhytidoplasty.

1 An instrument similar to an Illouz cannula, but without an opening.

2 A straight instrument with a small depression on each border to be used after instrument no. 1. 3 Similar to instrument no. 2, but even wider.

4 A nonsharp S-shaped instrument with a very small depression on the border of the concavity extremity and on the convexity on the other end

Fig. 39.5. Surgical instruments specially developed to perform rhytidoplasty.

1 An instrument similar to an Illouz cannula, but without an opening.

2 A straight instrument with a small depression on each border to be used after instrument no. 1. 3 Similar to instrument no. 2, but even wider.

4 A nonsharp S-shaped instrument with a very small depression on the border of the concavity extremity and on the convexity on the other end

Fig. 39.6. Subcutaneous tunnelization of the neck after hyperinfiltration. A straight instrument no. 1 is used to start the procedure. a It is introduced through the incision on the mastoid. b The instrument no. 1 is introduced through the earlobe incision

Fig. 39.7. The use of instrument no. 2. a External view . b It is introduced beneath the subdermal level through the earlobe incision with back-and-forth movements to perform subcutaneous tunnelization
Athstetic Healthy
Fig. 39.8. The use of instrument no. 3 and 4. a External views of instrument no. 3 on the right side of the face and neck. b It is introduced through the earlobe incision with forth-and-back movement just beneath the skin. c, d External view of
instrument no. 4. e It is introduced subcutaneously through the incision on the mastoid area in order to saw the remaining "bridges" after tunnelization

(Fig. 39.8). Thus, the small tunnels created by the Il-louz cannula are progressively widened all over the face and neck. These instruments are introduced through the same cutaneous incisions where liposuc-tion was done all over the hemiface and neck and are responsible for undermining without cutting the blood and lymphatic vessels or the nerves. Therefore, all vascularization from the depth to the cutaneous flap is preserved (Figs. 39.9, 39.10b). The tunneliza-tion procedure on the cheek until the mandible arch goes farther, close to the nasolabial fold. On the neck it goes even father until it crosses over the midline. The thickness of the skin flap which includes the subdermal layer is quite thick. On the area above the zy-gomatic arch, the tunnelization procedure is done beneath the temporal fascia in order to avoid any damage to the capillary hair bulbs. In that area the vascular network passes parallel to the skin in the galea. Therefore, there are no vessels coming from depth to the cutaneous flap.

So the whole area of the skin of the face and neck is dissected by tunnelization with minimal bleeding, since the vessels are preserved (Figs. 39.9, 39.10b). All these procedures are done in a closed-pocket system since the cutaneous incisions have not yet been performed. In addition, using extensive supraplatysmal tunnelization undermining communicates in the midline, from one side to the other, which makes the skin flap slide over the muscle.

This sort of tunnelization with a blunt and flat instrument, with some irregularities on the border of each side, is the fundamental difference between our

Left Side Right Side Face Comparison
Fig. 39.9. After tunnelization with nontraumatic instruments, the vessels are preserved with minimal bleeding. a Peroperative photograph of the left side of the face and neck of a patient. b Right side of another patient
Fig. 39.10. Comparison between cutaneous undermining. a Through traditional techniques, all perforator vessels were cut. b Through tunnelization undermining, most vessels were preserved

procedure and that of other techniques using scissors for cutaneous undermining which cut all vessels from the depth to the skin flap with abundant bleeding during and after (Fig. 39.10a).

Our idea came by observing male rhytidoplasty since men have very thick skin and normally abundant bleeding is present which bothers greatly the surgeon during and after the operation, and there is severe seroma formation. In fact, we do not use any kind of drainage since there is no bleeding during or after surgery. We have not had any case of severe hematoma in the postoperatory recovery. Since we published our new concepts for abdominoplasty as a closed vascular system [5], we started to employ a similar procedure in rhytidoplasty since the surgical principles are the same, i.e., to preserve most vessels in the cutaneous flap. In fact, the arteries maintain regular blood supply to the skin and the venous and lymphatic circulations work normally like multiples pedicles (Figs. 39.9, 39.10b).

Traditional rhytidoplasty with lipectomy on the submental and submadibular regions is a quite traumatic procedure since the dissection by scissors and removal of excess fat at the same time may provide good results but the skin flap may present excessive scarring and adhesions with an unpleasant aspect. Before the lipoplasty era, lipectomy was a very popular method, but was very radical and aggressive, with a high rate of complications [32]. Skin necrosis, infection and dehiscence of the wound are frequent problems after rhytidoplasty. Also trauma to the nerves may happen when scissors are used, although careful operation is performed by outstanding surgeons.

Therefore, nowadays a proper evaluation is a mandatory step before surgery and it is possible to choose a less traumatic technique.

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