Overall, postbariatric surgery (PBS) patients are relatively young. Similar to patients with HIV-associated lipoatrophy, the suspension properties of the midfacial skin have not been altered drastically. Instead, it is the massive weight loss that creates a hollowed appearance in otherwise convex areas of the face [9]. Therefore, more traditional midface lifting techniques are usually not indicated, and a variety of temporary and permanent volume restoration options have been developed and applied to the midface, perioral complex, and lip of the PBS patient.

In contrast to the midface, deformities in the jaw and neckline are caused primarily by skin excess and laxity and, therefore, are addressed solely by rhytidectomy techniques. Prior to bariatric surgery, pre and subplatysmal fat accumulation leads to stretching of the skin and platysma muscle. As in the rest of the body, postsurgical fat loss reveals stretched, inelastic, and redundant skin. In the neck, the anatomic area of interest is typically the anterior compartment between the sternocleidomastoid muscles. Again, however, a key difference between the aging patient and massive weight loss patient must be highlighted. The primary distinction lies in the pathomechanics, and subsequently the treatment, of the platysma muscle. In the aging neck, the platysmal muscle undergoes a decrease in tone as well as an increase in diastasis. However, in the PBS patient, there is less muscle diastasis and greater skin excess that is the principal issue. More conservative treatment of the midline platysma by plication is performed in these patients.

41.3 Preoperative Evaluation

As with all patients seeking cosmetic surgery, a thorough preoperative consultation will include not only the patient’s particular aesthetic defect, but also their exact expectations, a complete history, and physical and a quick assessment of their psychological and emotional well-being. In each of these areas, there are issues specific to the massive weight loss patient that must be addressed. First, timing of cosmetic surgery should be carefully planned. As mentioned previously, many PBS patients seek to correct their facial deformity prior to addressing other body contouring surgery. A recent meta-analysis has shown that the patient’s weight is likely to fluctuate within the first year and long-term weight loss is poorly described in

the literature [10]. Additionally, it is well known that skin will undergo some degree of contraction after 60% of the body fat is lost. Therefore, it is prudent to wait for 6–12 months to allow the skin to reach its final position and the patient’s weight to stabilize to avoid overcorrection.

Correction of midface deformities focuses on volume restoration. Areas of the midface that require particular attention are the tear trough/infraorbital rim, the malar eminence, the submalar region, and the nasolabial crease. These areas typically undergo the greatest volume loss. Additional areas of concern are the temporal fossa, jawline, and perioral region, and less commonly, the glabella and lateral brow. It is important to decide preoperatively (1) which areas to address, (2) the specific type of filler to be used and lastly, (3) the amount needed for effective volume replacement. There are scales described for both autologous fat transfer [11] and hyaluronic acid derivatives [12], but a universally accepted, standardized grading scale has yet to be established. If the surgeon is considering autologous fat, it is imperative to anticipate the amount of volume needed so that an appropriate amount can be harvested.

In the preoperative evaluation, there are unique anatomic considerations in each area of the face. Symmetry is of particular importance in the midface, as it is frequently variable and easily correctable. In the perioral region, restoration of the normal curves and convexities of the lip is essential to both redefine the shape of the lips as well as to reestablish the lip volume. With fat volume loss, the vermilion margin will flatten, and volume augmentation will allow the patient to regain the healthy, “pouty” look.

Evaluation of the lower face focuses not only on the skin, muscle, and fat of the submental region, but also the bony substructure, including the strength of the anterior jaw projection and position of the hyoid bone. Anterior mandibular deficiency, unless corrected, will allow cervical skin to hang in unaesthetic positions in the PBS patient. Failure to treat weak anterior bony projection seriously compromises the final results of rejuvenative surgery in these patients.

Even in the PBS patient, a significant amount of submental fat may still be present, and cervical liposuction is generally necessary to adequately define the cervicomental angle and lower jawline. Fat removal should be thorough, and also should be feathered peripherally. Excessive liposuction should be avoided, but “cobra neck” deformity [13] is uncommon because

of the relatively lower incidence of midline platysma diastasis. Finally, the overall degree of skin laxity must be assessed in order to counsel the patient set appropriate postoperative expectations. In cases of severe skin laxity, a truly youthful appearing neck and jawline may be impossible or require several revisions to fully redrape the skin.

Other preoperative considerations specific to the PBS patient include those related to their extensive comorbidities. While weight loss surgery can have a positive impact on related diseases, such as diabetes, the literature is controversial. Several authors have reported large cohorts of weight loss patients with significant reductions in comorbidities [14, 15] and mortality over time [16, 17] (up to 89% reduction at 5 years). However, a meta-analysis [10] which included only studies with greater than 3 years postoperative follow-up noted several flaws in the above-mentioned studies’ claims, as well as a statistically significant regain in weight for all of the series included at 10 years. For the cosmetic surgeon, the key to this controversy lies in the possibility that despite the initial weight reduction, many patients may return to obesity and retain their comorbidities, especially diabetes. It is important, therefore, that any contouring surgery be deferred for at least a year and extensive preoperative medical screening is performed on every PBS patient.

Other well-documented issues in treating the PBS patient include cardiac arrhythmias and nutritional deficiencies. Up to 10% of patients will develop new cardiac arrhythmias after bariatric surgery, and if any anomalies are identified on a preoperative electrocardiogram, a complete cardiac evaluation is warranted. PBS patients may develop hypokalemia and hypomagnesemia, and appropriate electrolyte evaluation should be performed preoperatively. Massive weight loss patients are at significant risk for caloric and nutritional deficiencies in vitamin A, vitamin B12, folate, vitamin C, iron, selenium, zinc, and protein [18]. For the facial plastic surgeon, important considerations are anemia, problems with wound healing, and poor immune response optimization. In an outcomes analysis of 139 patients undergoing contouring procedures after massive weight loss, 14.4% had wound complications [19]. To avoid these and other potential complications, preoperative screening and supplementation is recommended. Also common among these patients is gastroesophageal reflux, especially if any alteration has been made to the GE junction. Some preor

perioperative reflux medication may be indicated when operating on these patients. Lastly, these patients should be assessed for obstructive sleep apnea and potential difficulties with intubation, both of which are extremely common in all obese individuals.

As with any patient seeking plastic surgery, it is imperative to assess the patient’s psychological wellbeing. This is especially true in the massive weight loss patient. Studies have found a high rate of psychological abnormality among persons with extreme obesity who pursue bariatric surgery. Between 20% and 60% of patients have been diagnosed with axis I psychiatric disorders, the most common of which are mood and anxiety disorders [20, 21]. Additionally, binge eating is common among this population and can return at any time despite the massive weight loss. Patients should undergo preoperative psychological screening, such as a questionnaire to assess potential psychological pathology, especially eating disorders, body dysmorphic disorder, and emotional instability. Positive screening or suspicions should be referred to a mental health professional prior to any cosmetic surgical procedure. Finally, patients may have unrealistic expectations of their final results based on popular figures who have undergone bariatric surgery with contouring. These should be identified and realistic expectations should be discussed explicitly with the patient preoperatively.

41.3.1Rhytidectomy in the Postbariatric Patient

In tailoring a procedure for the postbariatric surgery patient, it should be kept in mind that the laxity, excess, and ptosis of the skin generally exceed those of the superficial musculoaponeurotic system (SMAS). Rhytidectomy in these patients is still a standard procedure with appropriate modifications. Rather than detail the complete procedure, described here are the important considerations and modifications to a standard SMAS rhytidectomy necessary in postbariatric surgery patients. The skin incision can enter the temporal hairline above the helical root only if the vector of planned facial elevation is predominantly posterosuperiorly, not superiorly, oriented; if the vector of flap movement is mostly superior in direction, the incision should course around the sideburn pretrichially to

avoid elevation of the temporal hair tuft. It should be remembered that post-bariatric rhytidectomy patients are generally younger than the traditional patient with an aging face, and are undergoing facial surgery to match their facial appearance with their rejuvenated body; these patients are often reluctant to commit to a specific hairstyle to camouflage an occipital scar. The vector of elevation in the neck can be mostly superior in direction, and with care the incision across the mastoid skin and into the hairline can be avoided. Patients appreciate the absence of this obvious portion of the scar, especially when seeking to resume a more active and athletic lifestyle. In patients with severe skin laxity, it may not be possible to contour the postauricular area smoothly without the occipital portion of the skin incision. The skin may “bunch” along the postauricular scar, but this can be redraped if the incision is extended into the hairline, or the scar can be revised 6–8 weeks after surgery as a planned, second stage. These options should be discussed preoperatively with the patient and a plan of action determined before surgery.

Suction-assisted or direct lipectomy, or both, in the submental triangle and jowl areas can be judiciously performed to assist in creating a smooth, contoured, sculpted neckline. In the midline, paramedian platysmal bands are identified and the edges undermined from the submental crease inferiorly to a point 1 cm above the thyroid cartilage. If the bands are particularly thick or prominent, a vertical strip of muscle is excised from the medial edge of each platysmal band. The platysmal edges are then sutured from superior to inferior with a running 3–0 polydiaxone suture, which then returns superiorly with wider tissue bites to be tied in the submental region. This creates a sturdy sling for support of the submentum. Correction of the deformity requires significantly more skin undermining than the typical rhytidectomy to redrape the elevated skin smoothly. Particularly in the patient with massive weight loss, the inelasticity of the skin increases the chance of a “lateral sweep,” and it is important that the skin flap be elevated and redraped in a smooth, ten- sion-free fashion. If poor chin projection is present, a chin implant should be placed to assist in defining the cervicomental angle. Occasionally, modest transverse skin excision from the posterior border of the submental incision may be necessary. SMAS elevation and imbrication are performed in the standard fashion, although, as stated earlier, relatively less elevation of

this layer is necessary than in the typical rhytidoplasty. The skin is then redraped and trimmed appropriately. The authors now treat all flaps with platelet-rich fibrin matrix (Fibrinet, Cascade Medical Enterprises, Inc, Englewood, NJ) to aid in hemostasis and wound healing. No drains are used, all incisions are closed, and a compressive dressing applied.

Postoperatively, early ambulation of the PBS patient is essential, as Aly et al. [22] noted a 9% incidence of pulmonary embolism in PBS patient undergoing abdominoplasty. Later, the patient should be assessed for residual skin redundancy. A “tuck-up” procedure may be necessary as early as 2–3 months postoperatively to address this additional skin excess; it is preferable to address this severe skin excess at a later date rather than overtighten the skin during the primary procedure, so as to minimize a “lateral sweep deformity.” At the same time, contour irregularities in the postauricular sulcus (not uncommon if the occipital portion of the incision is not used) can be treated with conservative resection.

41.3.2Volume Restoration of the Lower Two-Thirds of the Face

Volume loss out of proportion to skin redundancy is the primary element of acute midfacial aging after bariatric surgery. As such, aggressive skin redraping can easily lead to a “pulled” or “windswept” look, especially in the midface. Appropriate volume augmentation, especially in the submalar area can rejuvenate the face and reduce the chance of a “lateral sweep deformity” [23]. A measured approach to midfacial rejuvenation is essential to maximize results. Moreover, perioral volume loss, particularly in the lips, also ages the PBS patient’s appearance, and a comprehensive treatment plan is critical to success in this area as well.

Midfacial fat atrophy after PBS will lead to signs of aging out of proportion to the patient’s chronological age. Infraorbital hollowing and nasojugal troughs will lead to a “tired” and “sad” periorbital expression, and may also “unmask” lower eyelid fat pseudoherniation. Fat transposition blepharoplasty can be considered, but the volume of fat available is generally inadequate to correct the severe degree of volume loss present. Midface lifting provides inadequate volume, as the midface has atrophied, not descended. Volume

augmentation with extrinsic material is generally necessary to allow the skin envelope to properly drape over the midface skeleton. True bony deficiencies should be corrected with skeletal augmentation. Alloplasts (such as tear trough or malar/submalar implants) can be considered for additional midface volume, but should be used with caution, as a thinned soft tissue envelope will fail to camouflage the implant’s edges.

Perioral volumizing is performed in the nasolabial crease, marionette folds, and lips. Relatively speaking, nasolabial crease treatment is less critical in the PBS patient than in the typical aging patient. The nasolabial fold is highlighted by the lateral depression caused by malar soft tissue atrophy. Once malar volume is restored, conservative filling of the nasolabial crease is generally sufficient. However, volume restoration of the labiomandibular groove can further smooth the natural convexities of the lower face. Finally, restoring the volume of the lips not only effaces lip rhytids but reestablishes proper balance of the lower face.

Given the younger age of PBS patients, long-term correction is desirable. Additionally, larger volumes are generally required, which will also have significant financial implications. In light of this volume/ persistence need, autologous fat transfer, long-lasting hyaluronic acid derivatives (HA), calcium hydroxylapatite, and poly-L-lactic acid should be considered. A complete description of each filler is beyond the scope of this chapter; however, a brief review of the materials and their uses is reasonable.

Hyaluronic acid products are glycosaminoglycans (GAGs) that are found extensively in the native extracellular matrix of connective tissues. The hydrophilic composition of GAGs attracts water into the extracellular matrix conferring a degree of turgor to the tissue, which acts as a hydrating agent and increases its effect as a volumizing agent. Hyaluronic acid has the unique property of being identical in all species; therefore, its derivatives should not be antigenic across species. Lowe et al. [24] published a series of 709 patients who underwent injections of Hylaform or Restylane without preoperative skin testing. In three patients (0.4%), a delayed inflammatory reaction was observed at the site of injection. After transplantation, the hyaluronic acid derivatives undergo local degradation by hydrolysis and eventual metabolism by the liver. Commercially available injectables consist of hyaluronic acid derivatives that have been cross-linked to form a gel matrix

which prolongs their degradation in vivo. Several large series have confirmed the duration of the augmentation achieved with these compounds to be approximately 6–9 months [25–29].

These fillers are approved for mid-deep dermal injection; however, they may be used in an “off-label” fashion to provide large volume augmentation with both deep dermal and subcutaneous placement. Two to six cubic centimeters per side may be necessary, and care should be taken to blend the edges of the treated areas, especially in the nasojugal grooves, where these fillers need to be deposited in a supraperiosteal plane.

Similar in action to hyaluronic acid derivatives that rely solely on their own volume to augment soft tissues, a cross-linked porcine collagen has recently been introduced to use in the United States which can be similarly used and may persist longer [30].

Two other fillers are available that rely in part or fully on the body’s response to the injected material. Injectable calcium hydroxylapatite beads are suspended in a mixture of glycerin, water, and cellulose (Radiesse, Bioform Medical, Inc., San Mateo, CA). Once injected subdermally, collagen deposition around the beads provides additional volume correction which can last 12–18 months [31]. Even and smooth subdermal distribution is important; placement in the suborbital grooves should in general be avoided, as the thin overlying skin and soft tissues provide little camouflage or blending to the injected material, which may then be visible as a distinct mass.

Similarly, injectable poly-L-lactic acid (PLLA, Sculptra, Dermik Laboratories, Inc., Berwyn, PA) is a suspension of PLLA beads that are injected subdermally. A progressive fibrosis around the individual beads ultimately generates a thickening of the dermis and volume augmentation, but multiple treatments are generally needed [32]. At the time of this writing, PLLA is approved for HIV antiretroviral therapyassociated lipoatrophy, and FDA approval for cosmetic uses is still pending. However, the longevity of effect of 2 years or more makes PLLA a reasonable option for volume augmentation in PBS patients.

Autologous fat transfer remains the large volume facial filler of choice when a permanent solution is desired. In 1893, Neuber [33] first used autologous fat for soft tissue augmentation. Over the years, the use of adipose grafts in soft tissue augmentation has wavered due to the high rate of graft resorption, as well as the unpredictable degree of volume loss. With the advent