Q: D. Eppley, I need advice on a facelift result. I am a 63 year old female, who has lost 125 lbs from gastric bypass surgery over two years ago and had a facelift done two months ago. Sadly, my neck wattle has partially returned and both I and my plastic surgeon are very disappointed. In reading my operative note the facelift technique done was a lower facelift/corset platysmaplasty, lateral spanning sutures in platysma, and SMAS plication, with extremely wide skin undermining.
I am at a loss of what I or my plastic surgeon could have done differently! I don’t want to go back to surgery with the same plan which has already failed once. My plastic surgeon suggested the option of a direct neck lift but I don’t want the visible scar.
Do you have any experience with facelift surgery in massive weight loss patients?  Was I asking too much from this operation? I know my skin elasticity is terrible and there is some improvement but not a lot.

A: In my facelift experience with large neck wattle in extreme weight loss patients, the first thing I tell them is that their degree of neck laxity may require a secondary procedure due to rebound relaxation and an inability to adequately reposition all the neck skin up and back. What looks good on the operating room table may be inadequate or does not always hold up well. So plan the surgery as if it is a two-stage procedure.

The second issue is what I do during surgery…you will need a major back cut behind the ears that either extends well into the occipital hairline or goes along the occipital hairline down very low into the posterior neck. This is the only way you can find a place to redrape the neck skin and excise it. In necks like these it is all about incisional location and it is different than a more traditional facelift. This also applies to the anterior incision as well. Because so much skin is being moved, and I don’t want the preauricular tuft of hair to end up way above the ear, I do a blocking incision technique. This is where the incision is made not up into the temporal hairline but around the preauricular hair tuft in a Z-shaped pattern. Good mobilization and redraping of the skin with these incision patterns, will show intraoeratively that the entire ear is completely covered before you make pilot cuts and skin excision. If it is not, then the amount of neck skin redraping will be inadequate.

I would simply plan on doing a secondary facelift with these modified anterior and poster incision locations, doing skin only, and it will be much better than the first time. The reality is that this type of neck skin excess and poor elasticity defies a traditional facelift approach.

Dr. Barry Eppley
Indianapolis, Indiana