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  • Key Points
  • Description of the round-lifting technique.
  • Avoiding dislocation of anatomical landmarks.
  • Addressing the forehead.
  • Description of main ancillary procedures.
  • Overview of complications.
  • Short scar facelift in the MWL patient.

In the past few decades, facial aesthetic surgery has undergone enormous progress, with a greater understanding of anatomy and the development of newer technology and products that complement the operation. In our beauty-centered global society, where life is fast-paced, people are rapidly judged with regards to their appearance. The face is frequently the main focus of anxiety, especially in individuals who have attained a certain stage in their lives. Job competition, interpersonal relationships, and physical well-being are reasons that many times motivate the patient to come to the plastic surgeon seeking a more youthful look. On the other hand, bariatric surgery has permitted significant loss of weight in the morbidly obese. It has therefore become more common for the patient who has undergone a great amount of weight reduction to present to the plastic surgeon requesting the removal of excess skin from one or, more typically, many regions of the body. When there is redundant facial skin, this causes social embarrassment and needs to be addressed by a surgical procedure. The surgeon must be knowledgeable in details of different surgical approaches and variations thereof to attain the best result for each individual case. The round-lifting technique, as described by the senior author, is very well indicated for the treatment of excess facial skin, as the vectors of traction allow for the repositioning of tissues without causing anatomical distortion, such as dislocation of the hairline and visible signs of skin traction. Ancillary procedures present the surgeon with a vast array of surgical and non-surgical techniques that should be used in an individualized manner, as each patient presents differences not only in anatomy but also regarding regional complaints.
In this chapter, the surgical treatment of the aging face in the patient with massive weight loss will be presented, giving emphasis to the correct traction applied to the facial flaps (the round-lifting technique) and the forehead (the ‘block’ lifting), assuring that all anatomical landmarks are precisely preserved. The reader should note the importance of planning incisions for facial aesthetic surgery in this population, so that redundant skin can be removed without distorting key landmarks.
A satisfactory outcome of an aesthetic facial procedure is obtained when signs of an operation are undetectable and anatomy has been preserved. Visible scars and dislocation of the hairline are among the most common complaints, and everything should be done to avoid these stigmas. The round-lifting technique evolved with these concerns as its principal guidelines. Rhytidoplasty is one of the most frequently performed surgeries in the practice of the plastic surgeon. In the senior author’s private clinic, a total of 7927 personal consecutive cases have been analyzed to date (see Fig. 3.1). More recently, a noticeable increase in male patients has been noted. In the 1970s, men represented 6% of face-lifting procedures; in the eighties, approximately 15%; currently, 20% of patients who seek aesthetic facial surgery are men (see Fig. 3.2). After appropriate intravenous sedation and preparation, local anesthetic infiltration is performed. The standard incision is demarcated, beginning in the temporal scalp, and proceeds in the preauricular area in such a way as to respect the anatomical curvature of this region. The incision then follows around the earlobe and, in a curving fashion, finishes in the cervical scalp (Fig. 3.3). (This S-shaped incision creates an advancement flap that prevents a step-off in the hairline, allowing patients to wear their hair up without revealing the scar.) Variations of this incision are chosen depending on each case. The choice of which incision is most appropriate should have the following goals in mind: • the treatment of specific regions for optimal distribution of skin flaps,

Figure 3.1 Collated data for facial rejuvenation surgery, by age group, from the senior author’s personal clinic. Number of cases for 1957–1979, 2934; for 1980–2004, 4993. (Total number: 7927 cases.)

Figure 3.2 Grouping by gender for facial rejuvenation surgery. (Total number: 7927 cases.)

Figure 3.3 The classic incision, as described for the round-lifting.

• the resection of previous scars in secondary rhytidoplasty, and

• the maintenance of anatomical landmarks. Secondary face-lifts especially present elements that require different incisions, and the versatile surgeon will establish the

indications and advantages of each different incision often by using a sideburn incision to avoid excess hairline elevation. Undermining of the facial and cervical flaps is performed in a subcutaneous plane, the extension of which is variable and individualized for each case. A danger area lies beneath the non–hair-bearing skin over the temples, which we have called ‘no man’s land’, where most of the temporofrontal branches of the facial nerve are more frequently found. Dissection over no man’s land should be superficial, and hemostasis carefully performed, if at all. Larger vessels should be tied. The patient who has undergone a significant loss of weight will usually complain of the very heavy, fatty neck. Treatment of this area requires that the dissection proceed all the way to the other side under the mandible. With the advent of suctionassisted lipectomy, submental lipodystrophy is mostly addressed by liposuction, in a crisscross fashion

(Fig. 3.4)

. On the other hand, direct lipectomy using specially designed scissors may still be useful to defat the submental region, as has been described historically.

Following this, treatment of medial platysmal bands is carried out under direct vision. Approximation of diastasis is done with interrupted sutures, plicating down to the level of the hyoid bone. Undermining of the facial flaps is extended over the zygomatic prominence to free the retaining ligaments of the cheek.

Dissection of the deeper elements of the face has evolved over the past 20 years. Almost no treatment was advocated before the publications that first described the submuscular aponeurotic system (SMAS). The approach to this structure has been a topic of much discussion. Currently, we determine whether to dissect or simply plicate the SMAS only after subcutaneous dissection has been completed.

Pulling of the SMAS is done, noting the effects on the skin. Although extensive undermining of the SMAS was performed in an earlier period, it has been noted that plication of this structure in the same direction as the skin flaps, with repositioning of the malar fat pad, has given satisfactory and natural results.

The durability of this maneuver is relative to

the individual aging process.

Tension on the musculoaponeurotic system allows support of the subcutaneous layers, corrects the sagging cheek, and reduces tension on the skin flap.

Techniques that treat the pronounced nasolabial fold include traction of skin flaps, and traction on the SMAS or the fascial fatty layer, with variable results. Filling with different substances may also be done at the end of surgery, either with fat grafting or other material.

Direct excision of the nasolabial fold is reserved for the older male patient as a secondary procedure.

In very selected cases, this technique gives a definite solution to the nasolabial fold, with a barely noticeable scar that mimics the nasolabial fold itself. The direction of traction of the skin flaps is a fundamental aspect of the round-lifting technique.

In this manner, the undermined flaps are rotated rather than simply pulled, acting in a direction opposite to that of aging, and assuring a repositioning of tissues with preservation of anatomical landmarks. A second advantage in establishing a precise vector of rotation is that the opposite side is repositioned in the exact manner.

This vector of traction connects the tragus to Darwin’s tubercle for the facial—or anterior—flap. A Pitanguy flap demarcator (Padgett Instruments, Kansas City, Missouri) is placed at the root of the helix to mark point A on the skin flap

(Fig. 3.5)

. The edge of the flap is then incised along a curved line crossing the supraauricular hairline so that bald skin, not pilose, is resected. A key suture is located here.

Likewise, the cervical flap should also be pulled in an equally precise manner, in a superior and slightly anterior vector of traction, to avoid a step-off of the hairline. Key stitches are placed to anchor the flap along the pilose scalp at point B so that there is no tension on the thin skin at the peak of the retroauricular incision. Only when the temporary sutures have been placed will excess facial skin be resected. Skin is accommodated and demarcated along the natural curves of the ear, with no tension whatsoever

(Fig. 3.6).

Final scars are thus not displaced
or widened. The tragus is preserved in its anatomical position, and the skin of the flap is trimmed so as to perfectly match the fine skin of this region. When performing a brow lift, placing these key sutures at points A and B is mandatory before any traction is applied to the forehead flap, essentially blocking the facial flaps.

Forehead lifting Aging in the upper face becomes evident with a descent in the level of the eyebrow and the appearance of wrinkles and furrows, sometimes from an early age. These are a direct consequence of muscle dynamics, responsible for the multitude of expressions so characteristic of humans, and also due to loss of skin tone. The use of botulinum toxin has been a valuable adjunct to temporarily correct these lines of expression and
Surgical technique

Figure 3.4 Liposuction has been useful to complement a face-lift.
Figure 3.5 The direction of traction of the anterior or facial flap follows a vector that connects the tragus to Darwin’s tubercle. Excess tissue is marked with a Pitanguy flap demarcator.
Figure 3.6 The posterior flap has been rotated and fixed at point B. Excess facial skin is demarcated with no tension on the flap.
has been widely indicated as a non-surgical application, either by itself or as a complement to surgery. Elements of the upper face that must be considered preoperatively for any procedure are: • the length of the forehead and the elasticity of the skin, • muscle force and wrinkles, • the position of the anterior hairline, and • the quality and quantity of hair. An important decision to be made regarding a brow lift is the placement of incisions. There are basically two classic approaches: the bicoronal incision and the limited prepilose or juxtapilose incision. The first allows for treatment of all elements that determine the aging forehead, while hiding the final scar within the hairline. Certain situations, however, rule out this incision. Patients with a very long forehead or those who have already been submitted to previous surgery should not be considered for this incision, because they will have an excessively recessed hairline if the forehead is further pulled back. The final aspect will be displeasing, giving the patient a permanent look of surprise. Having blocked the facial flaps at points A and B, as described above, the forehead may be pulled in any direction, either straight backward or more laterally

(Fig. 3.7).

The amount of scalp flap to be resected is determined by the length of the forehead and the effect that traction causes on the level of the eyebrow. The midline is positioned, demarcated, incised, and blocked with a temporary suture. Sometimes no traction is necessary and no scalp is removed in the midline. Two symmetric flaps are created, and lateral resection can now be performed, allowing the eyebrow to be raised as necessary (Fig. 3.8). The second approach is the juxtapilose incision, performed when the patient presents with ptosis of lateral eyebrow and scant lines of expression of the forehead. The short distance
3 Approach to the face and neck after weight loss
Figure 3.7 Positioning of the forehead flap is done only after the facial flaps have been rotated and ‘blocked’. This avoids excessive elevation of the facial tissues and alteration of the hairline.

Figure 3.8 The midline of the forehead flap is fixed, and each lateral flap is tractioned according to the amount of correction required.

Figure 3.9 Correction of the level of the brow to a more elevated position may be done by the juxtapilose incision, with a subperiosteal blunt dissection.

required to reac

h the eyebrow region is easily performed by subperiosteal blunt dissection (Fig. 3.9). Endoscopic instrumentation has permitted treatment of the brow through minimal access, and has proved useful in selected cases.
Optimizing outcomes The effects of the round-lifting technique have been studied by analyzing the mechanical forces applied and the displacements produced. The method of finite elements was employed and, by means of computers, the relevant equations were defined. Human skin was modeled as a pseudoelastic, isotropic, noncompressible, and homogeneous membrane, and a computational study of the fields of displacement and the forces applied to the flaps during a rhytidoplasty demonstrated that the
direction of traction creates areas of tension that can be either negative or positive. These forces ultimately result in the correction of signs of aging. Interestingly, the vectors described in the round-lifting technique address both the main features that suffer distortion with aging as well as maintaining anatomical parameters. Although there were limits due to the variety of factors involved because of the complexities of human skin (basic properties and individual variations), the study holds a close parallel to a real surgical procedure.
Several surgical techniques are part of the armamentarium that a surgeon should have to enhance the result of a rhytidoplasty. These procedures may be complementary to the face-lift or may be indicated by themselves. Two of the more frequently performed procedures are blepharoplasty and treatment of the aging lip. In general these areas are treated as they might be in a non massive weight loss patient. Occasionally massive weight loss patients can be observed to have persistence of periorbital lower eyelid fat after their weight loss—not associated with generalized facial aging.
The short scar face-lift in the massive weight loss patient. Technique by Dr Alan Matarasso The short scar face-lift with or without fibrin sealant is the preferred method of treatment in all aging and massive weight loss patients. The characteristics of patients faces following massive weight loss are similar to the changes seen in the aging face. However, in certain massive weight loss patients, there may be a greater absence of subcutaneous fat, more loss of fixed points at areas of osteodermocutaneous ligaments, more damage in dermal elements and “better” scar formation. The face-lift technique is a result of a continuous evolution from the traditional open face-lift incision

(Fig. 3.10)

, into the modified open technique

(Fig. 3.11)

All of the patients who have had this short scar face-lift also had concomitant suction-assisted lipoplasty, and most (76%) underwent a submentalplasty with a platysmaplasty. The short scar approach provides

• a shorter more appealing, and well-hidden scar,

• essentially no hair abnormalities or changes in hair position or density,

• potentially shorter operative time, and

• greater patient acceptance at the expense of a slightly narrower operative field with limited access to the orbicularis oculi muscle and temporalis muscle. The short scar incision begins in the horizontal aspect of the sideburn ‘sideburn incision’, extends to the preauricular region (either pre- or posttragal), curves around the ear lobe posteriorly up to the postauricular notch, and ends in the sulcus approximately 2–3 cm above the lobule. It spares incisions in the temporal and mastoid areas (see Fig. 3.12).
The short scar face-lift may require additional midline platysmal work, accounting for the higher rate of submentalplasty than is done with the traditional face-lift (76% versus 10.6%). The face-lift procedure begins with liposuction of the neck through a submental incision. A subcutaneous neck dissection is performed and jowl liposuction through a preauricular stab wound. The midline platysma is then isolated. A wide strip wedge platysmaectomy is performed to shorten redundant platysma muscle and deepen the cervicomental angle. When fat excision is indicated, the exposed fat deep to the platysma muscle is excised under direct vision and eletrocoagulated to further reduce it. The medial (anterior) borders of the platysma muscle are then identified, and a back cut is performed at the
Ancillary procedures
Figure 3.10 Traditional open face-lift approach, which allows wider access (i.e. the temporalis muscle). Modified from Matarasso A, Rizk SS, Markowitz J. Short scar face-lift with the use of fibrin sealant. Dermatol Clin 2005; 23:495–504.
Figure 3.11 Modified open face-lift approach. In the course of evolving to a short scar lift this was useful. Modified from Matarasso A, Rizk SS, Markowitz J. Short scar face-lift with the use of fibrin sealant. Dermatol Clin 2005; 23:495–504.
level of the hyoid if indicated. The medial borders of the platysma are then sutured in the midline with nonabsorbable sutures. This medial vector pull on the platysma is important for defining the cervicomental angle and for the redraping of excess skin into the submental hollow that occurs with the short scar face-lift following the concept Pythagorium Theorem. It is not necessary or desirable to have excess lateral vector pull on the platysma. The authors have found that ‘fatty necks’ after being aggressively defatted often have a surprising degree of tissue elasticity and retraction and that less skin excision than expected is required accounting for the dramatic result that can be achieved in the short scar face-lift in ‘large’ necks. In contrast, thin necks in older patients with ‘chicken skin’ lack elasticity and have poor collagen structure in addition to the diminished number of pilosebaceous units normally found in neck skin. Consequently, no amount of excessive pulling or tightening ultimately overcomes these characteristics. Indeed, attempting to compensate in these situations by excessive pulling by any surgical approach is a futile exercise that does not benefit poorquality skin. Next, the face and neck skin on the right side is undermined widely beyond the sternocleidomastoid muscle and then across the cheek and along the jowl, freeing any retaining ligaments. The superficial musculoaponeurotic system (SMAS) in the face is addressed with a SMAS resection, SMAS plication, or anterior imbrication as indicated. The lateral platysma is tightened and secured to the mastoid fascia. Final subcutaneous contouring is done with a ball tip cautery. The skin flaps on one side are redraped obliquely and vertically, so that the mandible no longer represents a border to the advancement of the neck skin (Fig. 3.13). This is done while adjusting the flap position to minimize bunching at the proximal (anterior end of sideburn) and distal (posterior lodule) incisions. The addition
of the Tisseel glue provides a significant draping advantage in the neck and postauricular region and may result in not using drains which also enhances flap redraping though drains are liberally used and can be used with tissue glue. After the SMAS is tightened and the skin flaps rotated, positioned, and trimmed they are tacked at the apex with an absorbable suture and at the tragus with a 5-0 nylon suture. The tissue glue is sprayed in an even, thin layer (<1mL per side) on the undersurface of the flap and on the raw dissected surfaces through the sideburn, preauricular, and postlobule incisions (Fig. 3.14). The preauricular incision is then closed with 5-0 nylon suture. The Tisseel glue is sprayed in 60 seconds or less,
3 Approach to the face and neck after weight loss
Figure 3.12 5-STAR incision. Note incision inside sideburn hairline, extending preauricularly (either pretragal or posttragal) and for a short distance postauricularly (short scar transauricular rhytidectomy). Modified from Matarasso A, Rizk SS, Markowitz J. Short scar face-lift with the use of fibrin sealant. Dermatol Clin 2005; 23:495–504.
Figure 3.13 Flap redraping in an oblique and vertical vector before sealant application. Note the circle depicting the area of the jowl that was liposuctioned. With permission from Matarasso A, Rizk SS, Markowitz J. Short scar face-lift with the use of fibrin sealant. Dermatol Clin 2005; 23:495–504.
Figure 3.14 Intraoperative fibrin sealant application with dual-injection device before closing. Key sutures at the helical rim and tragus. The preauricular suture begins at the lobule and is then used in a running fashion up to the helical rim. Note the redundant postauricular skin that redrapes and flattens. This is aided by the fibrin sealant and ‘walking out’ the excess tissue while closing with staples. With permission from Matarasso A, Rizk SS, Markowitz J. Short scar face-lift with the use of fibrin sealant. Dermatol Clin 2005; 23:495–504.
and then external gentle pressure must be applied to the flaps with moist gauze for 3 minutes while avoiding shearing (Fig. 3.15). The postauricular sulcus incision is closed with staples carefully walking out the excess skin to avoid pleating. The transverse sideburn incision is closed from lateral to medial, similarly adjusting the bulge at the lateral end that can occur. At the completion of one side, the patient is turned and surgery continues on the opposite side. Finally, final hemostasis is obtained and sealant is sprayed at the submental incision, and while pressure is applied, the wound is closed with a 5-0 nylon suture. Three layers of gauze are applied and covered with a surginet dressing (examples; Figs 3.16–3.18). No unique postoperative care is necessary.
Facelifting in massive weight loss patients – timing and results Facial rejuvenation is a part of a comprehensive, staged approach to the patient. The results are very satisfying (following similar principles as in the typical indications seen in an aging patient) as this often completes the long journey of weight loss, facial scars are well hidden and heal demonstrably better than other anatomic sites. Facelift surgery can be combined with other facial or body contour procedures. Safety of combining procedures is determined by the patients medical history, overall operative time required, a coordinated team approach and the patient desires. The goals of surgery are improved contour and rejuvenation with the least conspicuous incision.
Blepharoplasty Although changes around the eyes generally accompany the aging process of the face, it is not uncommon to observe younger patients who complain of excess skin and baggy lower lids. In the massive weight loss patient, herniated fat compartments persist even after weight loss. There are several important points that should be emphasized regarding surgical technique. Final scars should be well hidden, lying in the supratarsal fold in the upper lids, and along the ciliary margin in the lower lids, when an
external incision is made. If possible, the incision should not extend beyond the orbital rim because of the difference in thickness between these two regions. Since the advent of laser resurfacing, there has been an increase in the transconjunctival access for removal of fat pads of the lower lids. When associated with a face-lift and/or forehead lift, as is generally the case, treatment of the periorbital region is done only after the face and the brow have been blocked, as traction of the flaps may alter the amount of excess skin that needs to be removed. The shape of the incision is tailored to each patient, matching the individual’s anatomical features and correcting for asymmetry when this is present. Both sides are demarcated before any infiltration is performed.
Complications in rhytidoplasty are infrequent yet can bring great distress to the patient and to the surgeon. • It is essential to eliminate from surgery patients who continue to smoke, as the risk for skin slough is greatly increased. Smoking must be stopped completely at least 2 weeks in advance. • In the immediate postoperative period, blood pressure must be constantly monitored by the nursing staff to prevent hypertension and consequently hematoma formation. • If an expansive hematoma is diagnosed, the surgeon may initially attempt to drain the collection at the bedside. Early identification and treatment of large hematomas is essential to prevent sequelae. • Nerve injuries, dehiscence, and other complications are infrequent and should be treated conservatively.
See Figures 3.19–3.23 for descriptions of clinical cases.
With the advent of bariatric surgery, the obese and morbidly obese person can significantly improve his or her quality of life. Nevertheless, these patients will present with excess skin covering in several different body areas, which requires the attention of the plastic surgeon. It has currently become more frequent for the plastic surgeon to be requested to improve the signs of facial aging in the patient who has undergone significant weight loss. Myriad variations of established techniques are available, allowing for the correction of loose facial skin without leaving visible signs that a surgical procedure was performed. When well understood and executed, the round-lifting technique has proven to be reliable in consistently improving the different aspects of the aging face. The short scar facelift variation has been demonstrated to be a feasable alternative in the massive weight loss population.
Figure 3.15 Fibrin sealant is applied within 1 minute and manual pressure for 3 minutes after application. During this time, wounds are closed. With permission from Matarasso A, Rizk SS, Markowitz J. Short scar face-lift with the use of fibrin sealant. Dermatol Clin 2005; 23:495–504.

Figure 3.16 (a and b) This 60-year-old woman underwent short scar face-lift, submentalplasty, upper and lower blepharoplasty, and periocular and perioral erbium laser skin resurfacing. (c and d) Postoperative views shown at 1 month. Note the dramatic improvement in neck contour with the short scar face-lift. With permission from Matarasso A, Rizk SS, Markowitz J. Short scar face-lift with the use of fibrin sealant. Dermatol Clin 2005; 23:495–504.

Figure 3.17 (a and b) This 64-year-old woman underwent a short scar face-lift, submentalplasty, and upper and lower blepharoplasty (transconjunctival). (c and d) Postoperative views shown at 2 months. With permission from Matarasso A, Rizk SS, Markowitz J. Short scar face-lift with the use of fibrin sealant. Dermatol Clin 2005; 23:495–504.

Figure 3.18 (a and b) This 55-year-old diabetic man underwent a short scar face-lift and submentalplasty after a 100lb (45kg) weight loss. (c and d) Postoperative views shown at 2 weeks. With permission from Matarasso A, Rizk SS, Markowitz J. Short scar face-lift with the use of fibrin sealant. Dermatol Clin 2005; 23:495–504.
3 Approach to the face and neck after weight loss

Figure 3.19 Before the advent of liposuction, scissors were used to perform an open lipectomy (a). This may still be indicated in the fatty, heavy neck, as seen in this 57-year-old postobese patient (b). The submental region was freed completely with scissors, permitting a redraping of the skin together with the round-lifting technique (c).
a b
Figure 3.20 A main complaint of the postobese patient is flaccidity of the submental region. Following ample liposuction of the submental area, the roundlifting technique allows for a repositioning of undermined facial and cervical flaps without causing dislocation of anatomical landmarks, as seen in this 49-yearold female patient (a, before; b, after).

Figure 3.21 Men requesting a facial rejuvenation are seen more frequently than they were previously. Currently, weight reduction is strong motivation for a rhytidoplasty, as in this 61-year-old man (a, before; b, after).

Figure 3.22 The correction of the heavy neck may include the creation of a superior-based adipose flap that rotates over itself (a). This may be useful to increase the projection of the chin. Following significant weight loss, this 65year-old female patient was submitted to the round-lifting rhytidoplasty together with the rotation of the submental flap (b, before; c, after).
3 Approach to the face and neck after weight loss

Figure 3.23 An atypical approach to the heavy neck and face may be indicated, as in this secondary face-lift. The incision becomes prepilose over the temporal hairline and then meets the opposite coronal incision, allowing for treatment of the forehead without dislocation of the hairline (a). This alternative incision was chosen in this 58-year-old female patient after weight loss (b, before; c, after).
Finally, the plastic surgeon should be assured that the patient understands that the purpose of any procedure for the aging face is to help the individual cross with enhanced selfconfidence the sometimes difficult path to a mature age, and not to return the patient to an earlier stage of life. Experience is necessary to investigate and appreciate these subjective motivations. This evaluation requires both empathy and openness toward the patient.
Acknowledgment The authors are grateful to Natale Gontijo do Amorim, M.D., for her close collaboration in the preparation of this chapter.
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