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CANNULA SELECTION 68 MARCH 2015 | Surgical Aesthetics SURGICAL AESTHETICS The face and neck require the use of very small cannulas. Dr. Stevens avoids liposuction in the face altogether. "I don't like to do liposuction in the face; it's very unforgiving, but I will certainly liposuction the neck," he says. "I use a very small cannula—2mm, maybe even 1mm. You have to be very careful. Always be conservative and under-correct in this area." When removing fat in the abdomen, back and fl anks, utilizing a variety of cannulas offers the best results. Rod Rohrich, MD, plastic surgeon, professor and past chairman of the department of plastic surgery at the University of Texas Southwestern Medical Center in Dallas, opts for a shorter cannula when working in the back and fl anks. "You should use a smaller, shorter cannula—8 inches to 10 inches—because you want to have a lot of control. If you have a long cannula, you can lose control of the tip and it can go places you don't want it to go," he says. "In the body, they have to be longer, but they still have to be small in diameter; otherwise you can have an increased chance for rippling and contour depressions." For larger thighs and abdomens, Dr. Rohrich and Dr. Stevens typically start with a larger cannula in the deeper fat layers, then graduate to smaller cannulas. "The safe areas to suction are the middle fat layer in the trunk, using a small 3mm to 3.7mm cannula. If you're going superfi cial, you should use an even smaller cannula because you then run the risk of having a contour depression," says Dr. Rohrich. For patients undergoing liposuction on the body, Dr. Stevens starts with a 3mm or 4mm cannula. "It's rare for me to use anything wider than that," he says. "If I'm getting started on a large abdomen, I use a 4mm cannula with a spiral opening, so it removes the fat very quickly." Once he removes the initial fat in the mid-layers, he switches to a cannula that has fewer ports to slow down the aspiration. "You can increase or decrease the aggres- siveness by the ports—the pattern and amount of holes in the cannula—almost as much as you can by changing cannula diameter," says Dr. Stevens. "The bigger the cannula, the better it aspirates in gen- eral; and the bigger the ports or the greater the number of side holes, the more it aspirates. But you have to be very careful," says Dr. Rohrich. "In many areas you want to take out a modest amount of fat and you want to do so without causing any contour problems. That's why using a smaller cannula with multiple, small ports will actu- ally make it more refi ned. You can selectively take off a lot of fat, but it does take a lot more work because you truly have to sculpt the area." Starting Small Jeffrey Klein, MD, the creator of tumescent liposuc- tion, has developed several cannulas for surgical supply company HK Surgical. His approach in the body is slightly different from Dr. Rohrich and Dr. Stevens. Rather than work with more aggressive cannulas fi rst, he starts with a small diameter cannula. "This is different than some sur- geons advocate," he says. "Where they advocate going in with a large cannula and removing all the fat you can, then going in with smaller cannulas to sculpt, my approach is the opposite." For most tumescent procedures, Dr. Klein starts with an 18-gauge Capistrano cannula—which has small, round apertures on one-and-a-half inches of the cannula—and treats the entire area. Then he moves to a 16-gauge Cap- istrano, followed by a 14-gauge Finesse cannula, which has oblong apertures on only one side of the cannula. "The Capistrano cannula is a little more aggressive, but it's a small cannula. It will penetrate all of the tissue planes very easily," says Dr. Klein. "Because the diameter is so small, there's very little resistance and we can be very accurate in placing the cannula." Starting with the smaller cannula offers two benefi ts, according to Dr. Klein. There is less patient discomfort and it reduces the risk of irregularities. "The smaller the PHOTO COURTESY OF HK SURGICAL Shorter cannulas offer more control when working in the back and fl anks. "If you have a long cannula, you can lose control of the tip and it can go places you don't want it to go."