INTRODUCTION
The number of patients classified by the World Health Organization (WHO) as overweight
(body mass index [BMI] > 25 kg/m2) or obese (BMI > 30 kg/m2)1 has been increasing in developing and developed countries, with an estimated 1.7
billion people in these categories2. Thus, the number of patients who manage to lose weight through lifestyle changes
or bariatric surgery is also increasing.
Despite the advantages and disadvantages associated with great loss of adipose tissue
after bariatric surgery, excess skin remains thereafter. This can be considered unesthetic
to society and the patient himself, causing a psychological impact3, which creates a demand for surgical repair involving dermolipectomy in about one
third of patients who stabilize their weight2.
Reparative plastic surgeries of patients after massive weight loss (MWL), that is
those who lose at least 45 kg or 50% of their body weight, have recently increased2,4; among them, rhytidoplasty is the least performed since the face is generally less
affected by substantial fat loss2,5,6. However, the demand for this surgery is growing.
Patients in whom weight loss affects the face present with a cutaneous surplus and
laxity of the platysma muscle, developing something similar to a "jowl," "dewlap,"
or "turkey neck"2,6,7 besides evident nasogenian grooves in the middle region of the face, chin, perioral
and periorbital areas, and eyelids, as well as the tip of the nose and earlobes in
such a way that the context contributes to the aspect of early aging.
To correct this aspect with the most esthetic and lasting results possible, we used
several surgical tactics that still meet patients' tissue quality. Due to the fact
that postoperative bariatric patients do not adequately absorb nutrients, they end
up experiencing a loss of skin tone and consistency and the superficial musculoaponeurotic
system (SMAS)4,8-10.
OBJECTIVE
This study aimed to explore the routine surgical tactics in the treatment of cutaneous
flaccidity and the SMAS in the face, neck, and platysma muscle of post-bariatric patients
in a teaching hospital, in addition to a superficial histological comparison between
their skin, subcutaneous cellular tissue, and the SMAS and those of the non-post-bariatric
ones, showing the experience of the authors.
METHODS
Operating room and medical record data of 2012-2016 were reviewed, and we surveyed
all post-bariatric patients who underwent rhytidoplasty at the Dr. Alberto Rassi Hospital
- General Hospital of Goiânia (HGG) in Goiânia-GO. The authors of this study declare
that the principles of the Declaration of Helsinki revised in 2000 were followed,
as was Resolution 196/96 of the National Health Council. All patients signed an informed
consent form prior to surgery. The present study was approved by the Research Ethics
Committee of Dr. Alberto Rassi Hospital - HGG.
Patients who underwent rhytidoplasty after losing at least 22 kg or 23% of their body
weight by bariatric surgery regardless of the technique and who achieved weight stability
for at least 18 months were included in the study.
We aimed to determine the number of primary and secondary cases and stratify them
by sex, mean age, BMI at the time of surgery, and intra- and postoperative complications.
Rhytidoplasty was the technique most commonly used by the team. This technique started
with an anesthetic procedure, most of it being performed using the infiltration of
anesthetic solution (0.5% lidocaine) and adrenaline (1:160,000 dilution); one extremely
collaborative patient allowed the use of local analgesia only. We marked the facial
midline, the area to be detached (lateral zygomatic, preauricular, posterior mandibular,
and cervical regions), and the site to be incised (preauricular, intracapillary temporal,
and retroauricular contour) (Figure 1). The platysma muscle was accessed using a submental incision, enabling its plicature,
treatment with poliglecaprone 4.0, and simple stitches with spilled knots. In the
face's detached lateral region, marking of the SMAS redundant portion is performed,
plicature may be performed5,11, or when the tissue is exuberant and presents with bulging by simple plicature, SMASectomy
may be performed (Figure 2). The skin flap is repositioned via resection of its excess (Figures 3 and 4) and sutured by planes with poliglecaprone 5.0 and Prolene 5.0 continuous stitches.
In men, the technique is different in that we make an incision in the rib fold region.
In all cases, a vacuum drain is introduced; it is removed when the output is equal
to or less than 20 mL/24 hours and the aspect is serous.
Figure 1 - Marking of the planned incisions.
Figure 1 - Marking of the planned incisions.
Figure 2 - Removal of the superficial musculoaponeurotic
Figure 2 - Removal of the superficial musculoaponeurotic
Figure 3 - Flap positioning.
Figure 3 - Flap positioning.
Figure 4 - Immediate result.
Figure 4 - Immediate result.
Suture removal occurs at 5-10 days postoperative, with weekly return up to 28 days
and results evaluated after 4-6 months.
The service routinely pays special attention to the patient's nutritional status and
provides nutritional supplementation (vitamin B12, elemental iron, fat-soluble vitamins,
calcium citrate, protein, etc.) whenever the results for a control laboratory test
were altered in the presurgical evaluation. Whenever possible, the parenteral route
was preferred for supplementation, which lasted for the period necessary to achieve
the goals (minimum laboratory reference values).
Histopathological study of the skin, fat tissue, and SMAS of randomized patients was
performed for comparative analysis. Samples were collected during the rhytidoplasty
procedure from 6 randomly chosen post-bariatric patients at 1 year postoperative in
the digestive tract and compared with 4 non-post-bariatric patients (who, for this
reason, did not participate in the study sampling). The mean age of the post-bariatric
patient group in this sample was 51 years, while that of the group of non-post-bariatric
patients was 59 years. There was no sex-based difference in these sample groups. Samples
were collected and immediately fixed in 10% formaldehyde solution. The fixed material
was embedded in paraffin and subjected to microtomy and specific staining. The prepared
samples were referred for analysis by the same pathologist, who followed a staining
protocol consisting of hematoxylin and eosin in addition to Masson's trichrome. They
were then subjected to a 100× and 200× optical microscopy assessment and images were
obtained using a digital camera coupled to the microscope.
RESULTS
During the analysis period, 32 patients (24 women, 8 men; mean age, 55 years; age
range, 46-61 years) underwent surgical treatment (Figures 5 and 6) and achieved weight stability for a mean 3.5 years. All patients underwent primary
rhytidoplasty.
Figure 5 - A. Preoperative frontal view. B. Late postoperative (6 months) frontal view. C. Preoperative lateral view. D Late postoperative (6 months) lateral right view.
Figure 5 - A. Preoperative frontal view. B. Late postoperative (6 months) frontal view. C. Preoperative lateral view. D Late postoperative (6 months) lateral right view.
Figure 6 - A. Preoperative frontal view. B. Late postoperative (6 months) frontal view. C. Preoperative lateral right view. D. Late postoperative (6 months) lateral right view.
Figure 6 - A. Preoperative frontal view. B. Late postoperative (6 months) frontal view. C. Preoperative lateral right view. D. Late postoperative (6 months) lateral right view.
The patients had a mean BMI at the time of surgery of 27.4 kg/m2 (Table 1). The mean weight loss was about 40% of the initial weight, approximately 47 kg (Table 2). No intraoperative complications were reported; regarding postoperative complications,
there were reports of small foci of unilateral preauricular epidermolysis in 6 cases
(18.8%), which were treated with usual dressings and small volumes of unilaterally
organized hematomas, as well as preauricular in 8 cases (25.0%), 4 of which were concomitant
with epidermolysis (Table 3) and treated with simple drainage. The procedure lasted for a mean 4 hours and 20
minutes.
Table 1 - Distribution of surgical patients by sex and age at the time of surgery.
Variable |
Frequency |
n* |
% |
Sex |
|
|
Male |
8 |
25.0% |
Female |
24 |
75.0% |
Age |
|
|
45-55 |
15 |
46.9% |
55-65 |
17 |
53.1% |
Table 1 - Distribution of surgical patients by sex and age at the time of surgery.
Table 2 - Distribution of surgical patients by mean BMI at the time of surgery and mean weight
loss before the procedure.
Variable |
Frequency |
n* |
% |
BMI (kg/m2) |
|
|
18.5-24.9 |
15 |
46.9% |
25.0-29.9 |
10 |
31.2% |
30.0-34.9 |
7 |
21.9% |
Weight loss (kg) |
|
|
20-35 |
10 |
31.3% |
36-50 |
8 |
25.0% |
51-65 |
12 |
37.5% |
66-80 |
2 |
6.3% |
Table 2 - Distribution of surgical patients by mean BMI at the time of surgery and mean weight
loss before the procedure.
Table 3 - Distribution of surgical patients by postoperative complications.
Postoperative complication |
Frequency |
Number of complications |
% |
Only unilateral pre-auricular epidermolysis |
2 |
6.3% |
Few organized unilateral hematoma |
4 |
12.5% |
Organized hematoma and epidermolysis concomitant and unilateral
|
4 |
12.5% |
Table 3 - Distribution of surgical patients by postoperative complications.
Histopathological analysis of the samples collected from the skin (Figures 7, 8, 9 e 10), adipose tissue (Figures 11 e 12), and SMAS (Figures 13 e 14) of postoperative patients indicated increased edema, peripheral lymphohistiocytic
inflammatory activity, and severe epidermis hypotrophy; increased inflammatory activity
and edema in all adipose tissue; and decreased fibrous collagen tissue thickness and
presence of fibroconjunctive tissue with decreased vascularization in SMAS compared
to non-post-bariatric patient skin.
Figure 7 - Normal skin. (Magnification: 200×. Stain: Masson's Trichrome.)
Figure 7 - Normal skin. (Magnification: 200×. Stain: Masson's Trichrome.)
Figure 8 - Post-bariatric skin. Diffuse edema and divulgation of collagen fibers are visible.
(Magnification: 200×. Stain: Masson's Trichrome.)
Figure 8 - Post-bariatric skin. Diffuse edema and divulgation of collagen fibers are visible.
(Magnification: 200×. Stain: Masson's Trichrome.)
Figure 9 - Normal skin. (Magnification: 100×. Stain: hematoxylin and eosin.)
Figure 9 - Normal skin. (Magnification: 100×. Stain: hematoxylin and eosin.)
Figure 10 - Post-bariatric skin. Peripheral lymph histiocytic inflammatory activity and severe
hypotrophy in the dermal thickness are visible. (Magnification: 100×. Stain: hematoxylin
and eosin.)
Figure 10 - Post-bariatric skin. Peripheral lymph histiocytic inflammatory activity and severe
hypotrophy in the dermal thickness are visible. (Magnification: 100×. Stain: hematoxylin
and eosin.)
Figure 11 - Normal adipose tissue. (Magnification: 100×. Stain: hematoxylin and eosin.)
Figure 11 - Normal adipose tissue. (Magnification: 100×. Stain: hematoxylin and eosin.)
Figure 12 - Post-bariatric adipose tissue. Inflammatory activity and edema are evident. (Magnification:
100×. Stain: hematoxylin and eosin.)
Figure 12 - Post-bariatric adipose tissue. Inflammatory activity and edema are evident. (Magnification:
100×. Stain: hematoxylin and eosin.)
Figure 13 - Normal superficial musculoaponeurotic system. (Magnification, 100×. Stain: hematoxylin
and eosin.)
Figure 13 - Normal superficial musculoaponeurotic system. (Magnification, 100×. Stain: hematoxylin
and eosin.)
Figure 14 - Post-bariatric superficial musculoaponeurotic system. Presence of decreased fibrous
collagen tissue in its thickness and fibroconjunctive tissue with decreased vascularization.
(Magnification: 100×. Stain: hematoxylin and eosin.)
Figure 14 - Post-bariatric superficial musculoaponeurotic system. Presence of decreased fibrous
collagen tissue in its thickness and fibroconjunctive tissue with decreased vascularization.
(Magnification: 100×. Stain: hematoxylin and eosin.)
DISCUSSION
Bariatric surgery has emerged as an effective and rapid possibility of weight control
in obese patients who seek to improve their health status along the lines recommended
by the World Health Organization, not only disease absence (hypertension, coronary
disease, pulmonary hypertension, diabetes, dyslipidemias, gastroesophageal reflux
disease, skin mycoses, etc.)7,12, but their complete physical, mental, and social well-being.
Plastic surgery plays a crucial role in healthy outcomes, promoting surgeries that,
roughly speaking, could even be called inclusion procedures since the patient whose
face was quickly transformed by weight loss can have his facial pattern restored.
Because the face is an area that the patient cannot camouflage using clothing, the
surgical procedure allows the patient to feel like the individual that he or she was
before, to better accept themselves and be better accepted by society.
Rhytidoplasty is indicated for patients after MWL, when they achieve weight stability.
The greatest weight loss usually occurs at about 12-18 months after bariatric surgery,
and it is prudent to wait about 4-6 months after that to assess whether the plateau
is maintained13. However, in our service, although we always wait for weight stability, it was not
always necessary to wait for a 45-kg loss (or 50% of the initial weight, defined as
massive weight loss) since many patients already complained and presented good surgical
indications even before that. These patients presented satisfactory postoperative
surgical results in relation to the initial flaccidity, with frank rejuvenation and
restructuring of the face and neck esthetic pattern.
Knowledge about facial changes resulting from aging is better established than that
involving changes in facial skin structure and histology resulting from MWL; however,
this group shows turgor decreases and losses of subcutaneous fat14,15. Skin thickness tends to decrease in the facial region12,15 despite signs of increased or no difference in thickness in other regions12. Additionally, there is an increase in the expression of collagen type III, an immature
collagen with lower healing capacity12,16,17; fibers become fewer and wider in number12,17,18; besides histological changes compatible with aging, such as loss of collagen fiber
cohesion and enzymatic degradation of loose tissue12,14,15,17,19.
It is not uncommon for post-bariatric patients to experience nutritional changes.
The literature suggests the use of nutritional supplementation to prevent or treat
nutritional deficiencies resulting from anatomical changes caused by surgical techniques8,20-28.
The main complications associated with rhytidoplasty in post-MWL patients are hematomas
and edemas, which usually disappear in about 2-3 weeks; paresthesia, with significant
improvement by about 2-3 months postoperative; and rare reports of skin necrosis or
paralysis of the mime muscles due to facial nerve injury, or even hypertrophic or
keloid scars in the retroauricular zones2, but the main complications in our study were small foci of organized preauricular
hematoma in 25% of cases, followed by small areas of unilateral preauricular epidermolysis
in 18.8% of cases. There are authors who do not perceive an influence of MWL on the
increase of postoperative complications compared to control groups29.
CONCLUSION
The surgical technique of rhytidoplasty in post-bariatric patients follows general
principles except for specific details of this group of patients, such as the most
aggressive plicature and treatment of the platysma muscle and the eventual need for
SMASectomy. Patients in the study group presented skin of worse histological quality
compared to those without the nutritional difficulties arising from weight reduction
surgery. That is, postoperative bariatric skin presents a worse collagen fiber arrangement
as well as exacerbation of the local inflammatory reaction, which in theory hinders
the healing process and procedure durability and increases the risk of local complications.
Nevertheless, perioperative complications were not different than expected, even for
patients who did not undergo bariatric surgery. Further studies are needed to establish
conclusions regarding the procedure's durability.
COLLABORATIONS
HLFG
|
Analysis and/or data interpretation, Conception and design study, Conceptualization,
Data Curation, Final manuscript approval, Formal Analysis, Funding Acquisition, Investigation,
Methodology, Project Administration, Resources, Supervision, Visualization, Writing
- Original Draft Preparation, Writing - Review & Editing
|
MGXPP
|
Analysis and/or data interpretation, Data Curation, Formal Analysis, Funding Acquisition,
Investigation, Visualization, Writing - Original Draft Preparation, Writing - Review
& Editing
|
DVS
|
Analysis and/or data interpretation, Data Curation, Formal Analysis, Funding Acquisition,
Investigation, Visualization, Writing - Original Draft Preparation, Writing - Review
& Editing
|
RKF
|
Analysis and/or data interpretation, Data Curation, Formal Analysis, Funding Acquisition,
Investigation, Visualization, Writing - Original Draft Preparation, Writing - Review
& Editing
|
RK
|
Analysis and/or data interpretation, Conception and design study, Conceptualization,
Final manuscript approval, Formal Analysis, Funding Acquisition, Investigation, Methodology,
Project Administration, Realization of operations and/or trials, Resources, Supervision,
Validation, Visualization, Writing - Original Draft Preparation, Writing - Review
& Editing
|
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1. Hospital Estadual Geral de Goiânia Dr. Alberto Rassi - HGG , Goiânia, GO, Brazil.
2. Hospital Universitário Ciências Médicas, Belo Horizonte, MG, Brazil.
Corresponding author: Hugo Leonardo Freire Gomes Avenida Dr. Ismerino Soares de Carvalho, 804 , Setor Aeroporto, Goiânia, GO, Brazil.
Zip code: 74075-040. E-mail: hugoleo@yahoo.com.br
Article received: April 24, 2019.
Article accepted: October 21, 2019.
Conflicts of interest: none.