After massive weight loss (MWL), most patients seeking body contouring surgery, especially the older ones, dislike the sagging skin of their face and neck. Some simply inquire, but for others, facelift is a priority among many operations. When total rehabilitation from skin laxity is desired, staging and finances are major issues. That often means that the facelift is piggybacked during second or third stage of body contouring surgery. The challenge is to analyze the facial and neck changes and execute a cost-effective plan. For comprehensive management of the body contouring patient, skill in facelift surgery is an advantage.

Aging and environment cause atrophy of the skin, adipose, fascia, and bones. Longevity, chronic disease, poor nutrition, sunlight, emotional stress, and smoking are progressive and permanent insults to a youthful face. On the other hand, facial sag after MWL is primarily due to adipose deflation compounded by gravitational descent. In young MWL patients with good skin elasticity, liposuction and augmentation (Coleman 1997) are important. In middle-aged MWL patients with good-quality skin and subcutaneous fascia, their long-term response to a well-performed facelift surgery is excellent.

MWL patients in their mid-forties and beyond progressively show classic changes, sagging jowls, poor jawline definition, and loose skin of the upper neck (Ellenbogen and Karlin 1980). Through incisions about the scalp and ear, the adherent skin of the lateral face and mastoid is released in order to mobilize the midface, lower face, and neck (Mustoe et al. 2011). A vertical lift to the subcutaneous fascia is the optimal antigravity vector to improve the lower face (Tonnard et al. 2002). After superficial fascial suture suspension (Mitz and Peyronie 1976) of the face, excess skin is removed along the temporal scalp and in front of the ear. The greater the tissue laxity, the greater is the amount of skin resection. Even then, patients need to be cautioned that pleasing early results may sag within a year due to poor post MWL tissue quality that cannot be predicted. The younger the patient, the longer lasting is the facelift. Excess fat in the neck is removed directly or through syringe liposuction. Facial fat atrophy maybe reversed by lipoaugmentation primarily in the cheeks and perioral region. While upper neck skin laxity will be reduced with the vertical facial pull, a complete correction includes strong oblique lateral pull of the platysma and mastoid skin. Thorough syringe liposuction of the submental region is performed through the lateral neck exposure. Six to twenty ml of usable fat for facial augmentation can be harvested. Medial platysma bands are pulled laterally (Mustoe et al. 2011) with low transverse transection of prominent medial muscle bands. Direct submental platysma plication is rarely indicated. Patients obsessed with their platysma bands accept the risk of prolonged postoperative swelling and induration after extensive submental surgery.

Two types of vertical lifts are being performed to meet the challenge of effective, efficient, and naturally appearing face and neck rejuvenation. The short temple incision vertical facelift corrects lateral facial flattening, indistinct jawline, hanging jowls, and sagging upper neck. The extended vertical lift lengthens the incision across the entire temple into the lateral forehead. That extension to the lateral forehead allows a temporal, lateral canthal and malar dissection that elevates the mid cheek, smoothes out lateral facial and lateral canthal wrinkles, and raises the lateral brow.