Your Questions

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

Q: Dr. Eppley, I have had a lap band for about 5 years and I have lost about 90 pounds and basically kept it off give or take an occasional 5 to 8 pounds. I would very much like to get rid of the remaining skin and fat in my stomach and upper torso area. I am searching for a surgeon who has quite a bit of experience with these procedures. I was planning on a local plastic surgeon do it but he is moving out of state and is booked solid. I only know of one other Dr. in this area who has extensive experience in this procedure on drastic weight loss, however, I do not choose to have him do this for me. I have consulted and been examined by my initial plastic surgeon about one year ago and he approved me for the surgery. I just was not quite ready at the time. I am now.  I am 66 years old. I am very active and always have been and am in very good health.
I would like to know if you are accepting patients from central Illinois, and if this is something that we can talk about the possibilities and the possible concerns of my not living in your area. I will likely have to self-pay, since my insurance company was approached as to if I would be covered for this procedure, and I was denied. They feel that it is cosmetic and not a necessity. Therefore I would also like to be informed of the cost involved. I would also like to have my breasts lifted and was wondering if it is possible to do both surgeries at the same time and the cost of that procedure as well. I think you in advance for your time and consideration.

A: Congratulations are your weight loss and, equally importantly, the ability to have maintained it. With a near 100 lb weight, you undoubtably have many of the typical findings that one would expect with  a resultant abdominal pannus and significant breast sagging. While I would ultimately need to see some pictures  of you to confirm your exact surgical needs, having done a lot of extreme weight loss patients (bariatric plastic surgery) over the years I can envision with some certainty as to your needs… an extended tummy tuck and full (type 4) breast lifts. It is very common to do both of those procedures together and it is safe to do so.

I have patients that come from all over the world for a variety of procedures so we are very familiar with how to handle patients from afar and can accurately foresee their needs and how they must be accomodated from afar. Doing a tummy tuck and a breast lift in a 66 year-old from afar would need to be done as an overnight procedure in our facility. The extent of the procedure (it is surprisingly not that painful) and your age mandates overnight observation for your medical safety. Whether you would then go directly home the next morning or stay just one more night in a local hotel is an issue to be discussed and also based on how you feel. You would go home with abdominal drains (you would have breast drains but those would be removed the next day) and those would need to stay in for 10 days at which time you would come back to have them removed. We follow all of our patients carefully using e-mail, photographs and texting, available 24/7, to handle any questions or needs. Thus you may be far away but are electronically just a click of a button close. All incision are taped so you have to provide no care to them and can shower with 48 hours, getting all tapes wet without any concerns about doing so.

Dr. Barry Eppley

Indianapolis,Indiana

Q :  I had gastric bypass surgery about six months ago and have already lost 65 lbs. At the pace I am going, I will reach my goal of 100 lbs within one year after surgery. While the weight loss is fantastic, the amount of loose hanging skin that has developed is disgusting. I want to get this loose skin removed as soon as I can. How soon once I reach my weight loss goal can I have plastic surgery?

A: It is understandable that most extreme weight loss patients want to enjoy the benefits from their efforts as soon as possible. While the weight loss is the first step, most patients will require some skin removal through a second stage body contouring surgery to really see the body that they had hoped for.

Despite the enthusiasm of pressing forward as soon as possible, it is important to wait until some point after you have reached your weight loss goal. Your body needs time to recover and adjust to the new weight. This also allows you to learn new eating habits that will help keep the weight off but also have you become more nutritionally sound.

Body contouring surgery places major stress on one’s body and requires a lot of nutrients and energy to heal properly. You also want your immune function to be functioning as best as possible. In short, you don’t want to be malnourished going into major surgery. It has been that many post-bariatric surgery patients have protein-calorie malnutrition as well as various vitamins and mineral deficiencies.

While there is no standard waiting period after bariatric surgery, it is best that one have a stable weight for at least three months before considering elective body contouring surgery. Patients who have had gastric bypass, due to intestinal absorption changes, aren’t usually ready for body contouring surgery for six months or more afterwards. Lapband patients lose weight at a much slower rate and it may be much longer than a year after their procedure before they are ready. Extreme weight loss patients who have done it on their own without surgery can be done sooner because their intestinal absorption of nutrients has not been altered.

Dr. Barry Eppley

Q: I’ve lost about 90 lbs and now I have excess skin that hangs on my upper arms that I want to have fixed.

A: One of the many skin problems that develops after large amounts of weight loss is that of loose hanging arms. The skin on the back of the upper arm in the triceps area hangs down, creating what is often called ‘bat wings’.  The excess skin frequently extends into the armpit (axillary) area and down into the side of the chest wall. Such large amounts of upper arm skin are a unique finding amongst extreme weight loss patients, particularly after bariatric surgery. Interestingly, this arm problem occurs overwhelmingly in women and not usually in men. (I have never performed an armlift in men) It may be that men’s skin shrinks down better after weight loss.

An armlift, known in plastic surgery as a brachioplasty, is an extremely effective procedure for reducing the size of the upper arms and getting rid of this loose floppy skin. While it accomplishes this result with the trade-off of a long arm scar, patients with this amount of loose arm skin consider that scar better than the excess skin. Armlifts are one of the most satisfying of all weight loss body contouring surgeries.

Armlifts traditionally have either placed the scar running down the middle of the inside of the arm or on the back of the arm. Recently, I am using a new technique during surgery that places the scar between the middle and the back of the arm with significantly better results.  The scar is not only better hidden but the common postoperative wound healing problems that used to occur (particularly when using the inside of the arm location) have been largely eliminated.

Dr. Barry Eppley