of liposuction in the 1970s, autologous fat grafting increased in popularity due to increased ease of harvest. Various other techniques for obtaining adipose tissue have been proposed, including syringe extraction and open harvest. Once extracted, the fat must be pretreated to remove inflammatory mediators and isolate the components necessary for implantation. Many authors have described techniques of fat washing, centrifugation, and filtration; however, no methodology is widely accepted as superior. Harvested and prepared adipose grafts generally are injected with a large-bore (14to 18-gauge) needle or cannula just below the dermis. Unlike the hyaluronic acid derivatives, a substantial overcorrection is required due to the large degree of resorption with time. Authors report that anywhere between 30% and 60% of the injected fat will be resorbed [34, 35]. However, mixing the adipocytes with an appropriate platelet-rich plasma [36] has been shown to enhance graft survival.

bruising is common, but typically last no more than 4–7 days [38]. If a subcutaneous nodule is prominent (particularly with the use of particulate fillers like calcium hydroxylapatite or PLLA), it may require excision if conservative measures (such as massage or corticosteroid injection) fail. This is especially common in the thin skin of the nasojugal groove if the injection accidentally infiltrates the orbicularis muscle. If hyaluronic acid products have been used, enzymatic degradation with hyaluronidase may be employed. Additionally, if a temporary filler is used, the patient will require periodic follow-up to assess for repeat augmentation; additional injections may be necessary as early as 4 months after the initial treatment, depending on the location, with highly mobile areas such as the lips typically requiring earlier retreatment.

Nutritional deficiencies are common in this patient population and should be suspected if poor wound healing is encountered. In these cases, diet modification, nutritional consultation, and even addition of a daily multivitamin may improve a patient’s result.

41.4Postoperative Care and Complications

Postoperative care of the massive weight loss patient following cosmetic surgery is relatively straightforward with a few exceptions. The postrhytidectomy patient is typically observed overnight and discharged in the morning after dressing change. The incidence of minor hematoma following rhytidectomy is relatively low (approximately 0.4–3%) and has recently been shown to improve with the use of fibrin glue prior to closure [37], and this is expected to be similar with the use of a platelet-rich fibrin matrix. Due to severity of the skin laxity, the skin may have a tendency to bunch along the incision lines. The patient must be instructed to massage these areas and the surgeon must note these on early postoperative visits to observe for possible revision. The patient may experience inflammation and ecchymosis for up to 2 months, but typically feel comfortable going out in public after 2 weeks [13]. There is a strong possibility of the need for minor revision procedures, which should be discussed with the patient postoperatively.

The patients injected with volume fillers must be continually assessed for significant absorption of the injected material and an irregular contour once the edema has subsided. Injection site swelling and minor

41.5 Conclusions

Massive weight loss results in an overall improvement in quality of life, but can cause significant facial cosmetic deformity. The loss of volume in the midface and severe skin laxity of the cervicofacial junction often leads PBS patients to seek facial contouring procedures. It is important for the cosmetic surgeon to understand the pathomechanics behind these aesthetic defects in order to appropriately address them. The midfacial and perioral volume loss is easily correctable with injectable fillers. The excess skin laxity can be fixed using the modified rhytidectomy technique (Fig. 41.1). To achieve an optimal result in a safe manner, a good understanding of the special preand postoperative needs of the PBS patient is imperative.

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