Of course, losing weight after bariatric surgery has many important health benefits; however, one drawback that many people experience is sagging excess skin, which can cause functional as well as aesthetic issues for patients. Body lifting procedures are a common solution to this problem, but it also affects the appearance of the face.
After a patient loses a massive amount of weight, the soft tissues in his or her face descend and lose their fullness. Forehead and cheek lines become more prominent, eyebrows droop, lips become thinner and less defined, and blood vessels and bone structures are more visible (Figure 1).
These facial changes can make you look angry, tired, haggard and much older than your years, and dealing with this image of yourself can lower your self-esteem and even lead to depression. Thus, some WLS patients turn to physicians to reverse the aged appearance associated with massive weight loss.
Nonsurgical Rejuvenation Therapies
Nonsurgical treatments are performed in an outpatient clinic setting and range from minimally to moderately invasive.
The least invasive, most gentle option for skin tightening is a skin care program that evens skin tone, exfoliates and stimulates new skin; these regimens generally take eight weeks and can be performed at home. Microdermabrasion buffs and exfoliates the skin and is performed in the office. Chemical peels range from superficial fruity peels to deeper, more concentrated acid peels; the more layers of skin the peel removes, the longer the recovery time, but it typically takes no longer than five to seven days. Lasers can also be used to remove layers of damaged skin and vary in strength and level of penetration (Figure 2). For deep skin peels, antiviral treatment is necessary to protect against infection.
Substances such as Restylane, Juvederm and collagen can be injected to fill depressions, wrinkles and folds in the face. This is done under local anesthetic and provides instant fullness with only a day or two of redness or tenderness afterwards (Figure 3). The results last four months to a year, after which the injection may be repeated. For your safety, only see a well-trained doctor for these procedures.
Another option to reduce wrinkles is Botox, which works by paralyzing muscles that pull on the skin. Botox injections can be used on the forehead and the area around the eyes, but are less effective below the eyes, as paralyzing other facial muscles may produce undesirable results.
Nonsurgical therapies allow you to avoid the downtime and cost of surgery; however, if you have goals that go beyond what minimally invasive therapies can provide, surgery may be a better option.
Surgical Rejuvenation Therapies
Surgical facial rejuvenation therapies can be more extensive and provide more long-term success. These include autologous fat transfer, dermabrasion, brow lifting, blepharoplasty (eyelid lifting) and face and neck lifting.
In autologous fat transfer, ?negative? fat from the patient?s torso is moved to the face to become ?positive? fat that fills out wrinkles and folds. The fat is gently harvested from the abdomen or thigh and then injected into the face through specialized tubes. Careful handling is critical to the success of this technique. Using the patient?s own fat makes this last longer than other injectable fillers; however, it may be more expensive per treatment, since it has to be done in the operating room.
Dermabrasion involves buffing the facial skin to reduce wrinkles, particularly those around the mouth. With more aggressive application, it will smooth out fine wrinkles, but it takes at least five to seven days for the skin to heal afterward.
Brow lifting corrects drooping eyebrows and is increasingly performed with endoscopic techniques that produce only minimal scarring behind the hairline. Blepharoplasty requires an open approach, but the scars are hidden in the upper eyelid crease and just below the lash line on the lower lid. Face and neck lifting techniques vary; those that involve tightening the muscles and removal of excess skin will help reverse the aging effects of weight loss. It is hard not to achieve remarkable results in massive weight loss patients (Figure 4).
Combined Therapies
Surgical and nonsurgical techniques can be used together to achieve a better overall result. For example, doing a facelift without addressing skin appearance has been compared to baking a cake without icing it; facelift patients may benefit from laser treatment or skin care before or after surgery, or from injection treatments after surgery.
Nonsurgical therapies such as fillers, lasers and Botox can combine to create a powerful result in the face, particularly in younger patients who have more elastic skin.
Multiple surgeries can also be done at the same time: some patients undergo the full complement of brow, eyelid, face and neck lifting, with fat transfer to fill out the contours of the face and dermabrasion for fine wrinkles (Figure 5).
If you have experienced facial changes after massive weight loss that are affecting your self-image and self-esteem, there are many solutions out there. Consult a board-certified plastic surgeon about the options available to restore a healthy and youthful appearance that matches how you feel inside.
Figure Legends
1. This 50-year-old woman lost 189 pounds after gastric bypass surgery and consequently looks older than her age due to her significant weight loss.
2. This 62-year-old woman lost 100 pounds after gastric bypass. She wanted a more refreshed look without surgery; laser treatments to her face and neck improved and tightened the appearance of her skin.
3. After this 26-year-old woman lost almost 300 pounds through diet and exercise, she had deep depressions and lines around her nose and mouth. Juvederm injections softened and filled out her face to better match her young age.
4. This 47-year-old woman lost 140 pounds after gastric bypass, resulting in advanced facial aging and sagging of the skin. She had a blepharoplasty and facelift performed to reverse this process and restore an appearance that reflected her age and upbeat attitude.
5. This 58-year-old woman had a facelift and dermabrasion performed to reverse her advanced facial aging, then came back after surgery for Juvederm injections into her lips and cheeks.
Michele Shermak, MD, FACS, is the Chief of Plastic Surgery at the Johns Hopkins Bayview Medical Center. She is board-certified and participates in the ASPS Bariatric Task Force.
September 2008