Lose sixty pounds and everyone tells you how great you look. Then you catch your face in a car window.
The body gets the credit. The face pays for it.
I know the bill by heart, because I dictate it at the exam.
“Facial aging with loss of volume from massive weight loss. She has ptosis, temporal wasting. She has festoons with excess lower eyelid fat bags, excess upper eyelid skin resting on her eyelashes. She has deep nasolabial folds and marionette lines. She has excess skin in the neck. And submandibular gland show.”
Every item on that list is the same event seen from a different angle. The fat left. What it was holding up came down, and what it was covering showed through.
People call it Ozempic face. Bariatric patients had it long before the pen. It is deflation, and the fix follows from the diagnosis.
“Fat is the best filler for a deflated face. A deflated face has lost fat. And what we do when we do fat grafting is replace the fat in those spaces. So it’s like with like.”
That is the whole argument, and I would stop there if patients did not keep arriving with something else already in their temples.
“Many people are using other fillers like Sculptra. But we have to keep in mind that these fillers create scar tissue and fibrosis, which may make the facelift procedure more difficult. It creates collagen through an inflammatory reaction.”
Read that once more if you are on your third round of a biostimulator. The volume it gives you is scar, and scar is what I have to lift through later.
“And last, we have hyaluronic acid fillers, which are temporary, tend to dissipate into the tissues, and can look unnatural. I think they have value in areas that need small corrections and superficial corrections, but not to replace the fat that’s lost due to massive weight loss.”
A man who lost fifty pounds after a sleeve came to me having tried Sculptra and been unhappy with how long it lasted. He wanted permanent. Here is what I told him.
“We overfill the areas, because he will lose about thirty to forty percent of the transferred fat. The remaining fat is permanent, though it will fluctuate with any future weight changes. Even at a low BMI of twenty one to twenty two, there is enough fat to harvest. The inner thighs are the best donor site, followed by the lower back or abdomen.”
Then there is the question of the knife, and when.
“Preferably I want the patient to have lost the weight that they had planned and be weight stable after any facelift procedure. The reason being that oftentimes patients after a facelift tend to lose further weight. And of course, if we lose the volume, then we will have some aging. As the face deflates, the skin tends to sag. So we would lose a lot of the benefit of having done the facelift if the patient continues to lose weight.”
The fat can go in early.
“In terms of fat grafting, it can be done while the patient is still losing weight, as long as the patient knows that it will require repeat treatments. But fat is one of the best fillers we can use, as it is natural, it is soft. It is the same tissue that belongs in those spaces, and can help slow down the aging process as the patient is losing weight.”
Two procedures, two clocks. Fat while the scale is still moving. The lift when it stops. Same rule as the body: you do not tighten what is still shrinking.
And when the lift does happen, in a post weight loss face, it is more than a pull. From a consult with a woman who lost thirty pounds on a GLP-1:
“It would bring this back as well and fill in the cheekbone, bring it back up. And then it’s gonna also bring your neck back tight. So it does give you, it removes about fifteen years.”
She had come in asking for a brow lift.
“Your upper eyelids get better when I do this. So I don’t think you need anything on your upper eyelids. There, you see that hooding. That is the skin. But when I do this, it fixes it.”
Fewer operations than she expected. Better order than she expected. That is usually how these consults end.
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