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Megaliposculpture refers to the aspiration of 10 l or more by liposuction. The author describes the procedure and the before and after care as well as possible complications. The author has had many successful results from the procedure. The author shows many of these patients and their follow-up. However, because of advances in bariatric surgery, drugs, and diets, there is no longer a need for this complex operation.

For a long time, surgeons hesitated to extract more than 2.5 L of adipose tissue from a patient during liposculpture. Through the years, the technique has advanced, now allowing megaliposculptures to be performed so that more than 10 L can be extracted without posing any greater risk to the patient than would a conventional aesthetic liposculpture. This article traces the progressive evolution of the technique through the years, also discussing complications and the concept of megaliposculpturing. The syringe-assisted extraction of large quantities of adipose tissue without transfusion, hypovolemic shock, or any major complication opens new horizons in the symptomatic treatment of certain types of osteoarthritis of the lower extremities and of the acquired or potential complications of obesity. Large quantities of adipose tissue may safely, quickly, and efficiently be extracted. Numerous investigations in various pathological domains can now begin after this first step (megalipotherapy). Therapeutic megalipoextraction can be done either as a preliminary indication or as a treatment of the residual adiposities that occur after bariatric operations.

An esthetic surgeon by definition must create or conserve beauty. The surgeon often finds it difficult to define beauty, and he is not alone. Ask different people and the answers vary considerably and, mainly, are not satisfactory. The author felt that it would be useful to approach the subject from a psychological point of view, and attempt to understand what it is that enters the mind of a person, esthetic surgeon or not, when he/she perceives, or does not perceive, the feeling of beauty. It is important to understand this feeling within us in order to guide us during our operations.

Choosing a technique of breast reduction today may be difficult for a young plastic surgeon. Will he choose a lateral technique or a technique with an inverted T? A bipedicle technique, horizontal, or vertical? With one pedicle or two pedicles? Oblique, superior, or inferior? With skin undermining or no skin undermining? Which technique is the safest and gives the best results? Some techniques are praised and others are denigrated by experienced surgeons with a reliable opinion and an authority in breast reduction. The choice of the young surgeon is in addition more difficult in the apparent difficulties of the techniques that are described. But is it the technique which is a bad or the surgeon? The author believes anyhow that the situation is simple.

Following facial or face and neck rejuvenation, it should be normal practice to prescribe similar treatment for the hands. In the aging process, the hands shrink, the veins appear more bulging and more colored than in youth, and the complexion darkens. Hyperkeratoses appear, multiply, and spread. The various types of procedures available to rejuvenate the hands are described such as hand lift, dermabrasion, vein stripping, chemical peel, and autologous fat. The technique of fat transfer to the hands is discussed including possible complications. The author proposes that the fill of the dorsum of the hand and fingers is more durable than that of the face fill. This has been one of the most satisfactory operations of fat grafting for the patient and the surgeon. It can be combined with a light peel and electrocoagulation of senile keratoses.

Liposuction is a blind and tactile operation and even in the best hands defects may occur. Defects can occur during liposuction but may be avoided by using the pinch test during the operation to warn the liposuction surgeon that removal of fat has been uneven. Should the liposuction surgeon be unhappy with the liposuction correction, he or she should reinject a variable amount of the patient’s own fat, 60–100 mL or more, which will give a more homogeneous result. Postliposuction defects may be seen shortly after the surgery or 4–6 months after surgery. They are visible and palpable and are seen more often when only one approach has been used. The skin may be very adherent to the aponeurosis in some places or a thin layer of fat may be present. In certain cases, the whole uneven areas can be treated together. In other cases, each elevation and each depression is treated separately. When there is not enough fat to remove for grafting in the uneven areas, the fat is very carefully taken from another place on the patient’s body.

The oval shape of the face may be lost on its lower por­tion, on both sides of the face in young, mature, or old people. This aesthetic defect is named “jowls.” Jowls may be of different kinds: 1. They may be due to a pure buccal fat ptosis without subcutaneous fat accumulation and this is treated by buccal fat extraction only.2. Buccal fat ptosis may be associated with a localized fatty subcutaneous accumulation and buccal fat ex­traction has to be associated with liposuction of this fatty accumulation also responsible for these jowls. 3. Another kind of jowls may be due only to a localized subcutaneous accumulation of fat and this aesthetic anomaly is treated by localized liposuction. 4. Finally jowls may be due to a simple localized or generalized skin excess on the lower face without lo­calized subcutaneous fat accumulation or buccal fat ptosis (pseudojowls or false jowls).

Most of the muscles of the nose are elevators with only one antagonist, the depressor septi nasi muscle. In ag­ing over time the tip of the nose droops. In other indi­viduals, the nasolabial angle is much less that the 110° that is accepted as a nice angle. Sectioning the depressor septi nasi muscles will slightly lift the nose in most in­dividuals (Fig. 67.1). After sectioning, the levators will increase their pull and will improve the nasolabial angle by a few degrees [1–4].

The idea of lifting selected parts of the face with subcutaneous sutures is not new. The aim is to tighten the subcutaneous tissues as well as the overlying skin. This procedure has the advantage of lifting the desired parts of the face or the upper neck without scar, under local anesthesia, with little downtime and minimal discomfort and complications as it is a minimally invasive procedure.

The white portion of the upper lip may have a short dis­tance between the Cupid bow and the opening of nos­trils. The upper teeth are seen very little during a smile or at rest. A moderate but notable very noticeable elon­gation may be obtained by a section of the frenulum (Fig. 71.1) of the upper lip on all its length.

The use of the syringe has been an advance in reduction and incremental liposculpturing. A real democratization in the medico-surgical group has been possible owing to the simplification of the equipment. The shock-absorbing action of the syringe makes the operation safer. Excellent results are obtained because one does perfectly symmetrical work. The syringe is a unit of measurement in this surgery of volume.

The author initially obtained the information on this subject from Paule Regnault in Montreal, Canada. During an upper cosmetic blepharoplasty, the estima­tion of the skin resection is usually done using the “pinch technique” [1]. It is satisfactory in many cases but quite often skin excess remains in the immediate fol­low­up and the patients are not fully satisfied and re­quest an “additional touch­up.” Many prudent aesthetic surgeons prefer to remove “less” than to remove “too much” and doing a touch­up is better than having a pa­tient unable to close his/her eyelids.

The Caucasian eye may have two different palpebral openings. Most often, it is almond­shaped. The trans­versal axis measured from the inner to the outer canthus is about 30 mm long and the most important height is from 12 to 15 mm. In another case, the height of the palpebral opening may be more important than in the previous case in relation to the transversal axis, giving the so­called aspect of “the round eye.”

Normally, in the function of the smile, the lips are re­tracted and elevated to expose a portion of the upper incisor teeth. In some cases, the lip retraction is too ex­treme and it exposes all of the incisors plus a large por­tion of gum above. This produces the so­called horse smile or gummy smile (Fig. 73.1), the correction of which was described by Rubinstein and Kostianovsky [1]. The operation is a relatively simple one that can be performed on an outpatient basis or in a well­equipped office. The results obtained are good.

The aging lip may have lines, wrinkles, and pigmenta­tions and often the distance between the base of the columella and the Cupid’s bow is increased owing to laxity of the skin or loss of volume. The Cupid’s bow then appears flat.

Summary Konrad Lorenz's theory of beauty is developed in detail. To elicit a protective desire, an adult's face must display childlike traits or expressions, called beauty. The emotion of beauty is subjective. The personality and the qualities of the individuals also relevant. In those who feel this emotion, it is largely influenced by the emotions of their earlier life.

Proper equipment is necessary for any successful operation. The syringe enables surgeons to remove subcutaneous fat more easily, more precisely, and less traumatically than with a suction pump. There is a sound basis for this conclusion.

We have used the honeycombed suction lipectomy (wet and/or dry) in over 700 patients. It represents a major advancement in the treatment of the localized adiposities of the body. Its advantages are eliminating the need for long, unsightly scars and reducing operating time and morbidity. Selection of appropriate patients is of paramount importance for reliable results because this technique is truly sculpting of the soft tissues. Results improve also with the proper training and experience of the surgeon. The indications and complications have been discussed. This technique (honeycombed suction lipectomy) appears more reliable than suction curettage that employs sharp dissection.