Postbariatric Surgery

Facelift Without Surgery

An alternative approach to perioral rhytides

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Given the epidemic of obesity that has af icted Americans, gastric bypass surgery—its multiple variations known collectively as bariatric surgery—has become increasingly popular. More than 103,000 bariatric surgical procedures were performed in 2003.75

Between 15% and 20% of patients undergoing bariatric surgery eventually seek plastic surgery once their weight has stabilized. A patient's weight must usually be stable for 1 year before plastic surgery is considered to correct skin excess. Potential areas and procedures include the abdomen, the thighs, the hips, arms, and face and neck. Each patient may require multiple operations to treat multiple areas, and the estimated number of these operations is substantial.

Patients seeking facial rejuvenation after massive weight loss present with many problems similar to those of other facial rejuvenation patients, but they also have some unique problems. Massive-weight-loss patients tend to have substantially more excess facial and neck skin. They also may have soft tissue atrophy in the submalar areas and deeper nasolabial folds than do patients who present with facial aging only. Therefore, in addition to cervicofacial rhytidectomy, other procedures may also be required at the same time or in the future.

A common first-step in these patients includes a face and neck lift and platysmaplasty. Skin incisions should be altered with the realization that a large amount of excess skin will be excised. Therefore, both the temporal and the postauricular hairline should be preserved. Hair-bearing skin should not be excised. A horizontal cut along the sideburn-cheek junction anteriorly with a vertical incision extending just posterior to the anterior hairline is the desired anterior incision.76 Posteriorly, the postauricular incision should follow the posterior hairline at the neck-hairline junction. Further posteriorly, the incision should extend into the hair-bearing scalp. Because of the large amount of excess skin that may be present in the submental area, the patient should be warned that some excess skin may recur in this area and may even require secondary correction.

Marked soft tissue atrophy in the submalar area may be an indication for placing submalar Silastic implants at the time of face and neck lift. We prefer this technique for treating soft tissue atrophy in this area. The submalar implants tends to provide permanent augmentation, do not resorb, and avoid the difficulty of harvesting fat in a patient who has already undergone massive weight loss.

Secondary surgery, in women as well as men, may include a direct excision in the area of the nasolabial folds because of their marked depth (Figure 9-11).

In summary, the patient undergoing facelift surgery after massive weight loss may require not only cervicofacial rhytidectomy but implant augmentation in cases of severe soft tissue atrophy. Secondary procedures, including revision neck lift and excision of the nasolabial folds, may also be in order.

Direct Excision Nasolabial Folds
Figure 9-10. Preoperative a) frontal and b) lateral view of a 76-year-old man who underwent direct skin excision of the neck with Z-plasty and platysmaplasty. c) Frontal and d) lateral view of the patient 6 months after anterior lipectomy and platysmaplasty.
Nasolabial Fold Surgery

Figure 9-11. a) Preoperative view of a 58-year-old woman who recently lost 110 pounds. b) The patient 1 year after a facelift, secondary direct excision of the nasolabial folds, and CO2 laser resurfacing of the scars. (Reprinted from Plastic Surgery 2/e, Mathes SJ, chapter: Face Lift (Lower Face): Current Techniques by Fardo D, Zins JE, Nahai F, ©2005 Elsevier Inc. With permission from Elsevier.)

Figure 9-11. a) Preoperative view of a 58-year-old woman who recently lost 110 pounds. b) The patient 1 year after a facelift, secondary direct excision of the nasolabial folds, and CO2 laser resurfacing of the scars. (Reprinted from Plastic Surgery 2/e, Mathes SJ, chapter: Face Lift (Lower Face): Current Techniques by Fardo D, Zins JE, Nahai F, ©2005 Elsevier Inc. With permission from Elsevier.)

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