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Key Points
- Anesthetically, patients with high BMI have more potential airway issues, as some exhibit obstructive patterns.
- Deep vein thrombosis also an issue with high BMI patients.
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Dr. Niamtu
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ANY SURGEON VERSED IN RHYTIDECTOMY is well aware of the challenges in operating on patients with high Body Mass Index (BMI). The BMI is calculated by dividing the body weight of an individual by the square of his or her height. Although there is variation and controversy associated with this formula, it is a useful general guideline to classify patients as underweight (less than 18.5), normal range (18.5 to 25), overweight (25 to 30) or obese (over 30). Patients in the 25 to 30 range present challenging anatomy for the facelift surgeon. These patients frequently have excess face and neck fat with or without skin excess. Not only is the subcutaneous fat abundant, but these patients also have increased accumulations of jowl fat, peri-parotid fat and submental fat (figure 1). Larger round faces and short thick necks can further accentuate the problems for facelift outcome.
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Normal fat distributions in patients with average BMI (left) vs. (right) a model of a silicone Hollywood prosthetic used to simulate increased BMI on actors which is consistent with accumulations of excess adipose tissue in patients.
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In addition to a technical challenge, this morphology can present problems with anesthesia and recovery. Anesthetically, these patients have more potential airway problems, as some of them exhibit obstructive patterns. Deep vein thrombosis (DVT) and pulmonary embolism is also potentially more of an issue in patients with high BMI's. In the immediate post-recovery period, airway problems are also a concern, as is DVT in the recovery process. Keeping these potential problems in mind, they have not been an issue in my personal experience in this population.
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Figure 2. The yellow lines represent the extended incisions utilized in high BMI patients. Figure 3. The blue region represents the extended lipocutaneous undermining in patients with increased BMI. Figure 4. Extensive submentoplasty requires larger undermining than a patient with a lower BMI. The blue region is indicative of the undermining of the submental and lateral cervical regions. The red area represents excess midline tissue that is clamped and excised during the procedure.
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SURGICAL PROCEDURE I perform most surgeries in an accredited office ambulatory center for healthy patients. My preferred anesthetic technique is IV sedation with very little narcotic and midazolam, Ketamine and propofol. My preferred means of airway support is a laryngeal mask airway (LMA), which provides a protective airway and the ability to ventilate the patient if necessary. Some anesthesiologists will also use anesthetic gasses with LMA. In my experience, these cases require extended pre- and post-auricular incisions as there is generally significant skin to be managed. A longer posterior auricular incision is used and an increased temporal pre-auricular component is also necessary (figure 2). In normal facelift patients, I prefer to make the posterior auricular incision high in the hairline, at or above the greatest width of the pinna, but in higher BMI patients I prefer to use a lower occipital hairline incision so as not to alter the posterior hairline. These patients also require a generally larger lipocutaneous flap dissection that extends to the lateral canthus and further in all directions than the same lift on a patient with a lower BMI (figure 3).
TECHNIQUE NUANCES Perhaps the most important step in managing patients with increased BMI is the submentoplasty. Most of these patients exhibit extremely full submental regions and although redundant skin may not be apparent pre-operatively, it can be extreme after aggressive submentoplasty.
After tumescent infiltration, an incision is made approximately 5 mm inferior to the submental crease. This slightly lower incision allows dissection above the submental crease, which frees the crease and can improve a ptotic chin. If the incision is made in the crease as many surgeons commonly do, the crease can be accentuated and contribute to a "witch's chin" deformity.
The next step is submental and anterior cervical liposuction. Since there is abundant adipose tissue, a larger cannula is used and aggressive liposuction is performed. Since the submentoplasty will be aggressive, it is important to leave an adequate amount of subcutaneous fat on the neck flap to prevent the deformity of dermal adhesion to the platysma.
