Seeking Advice: Managing Severe Facial Laxity in a Post-Surgical Patient

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I would like to share a case and seek insights regarding management strategies and realistic expectations in advanced facial flaccidity.

A 72-year-old female presented to our clinic seeking improvement of her face and neck, specifically inquiring about Endolift treatment.
Her medical history is significant for lung cancer (status post complete lobectomy), COPD and emphysema, breast cancer, and a current smoking habit (approximately 10 pack-years). She underwent two surgical facelift procedures, the most recent approximately 15 years ago, which yielded unsatisfactory results and required revision surgery.

The patient had consulted multiple plastic surgeons, all of whom ruled out a surgical approach due to her high perioperative risk and comorbidities.

On examination, she exhibits:

• Severe skin laxity

• Marked solar elastosis

• Significant skin detachment from underlying tissues

• Residual scars and stigmata from previous facial surgeries

We had an extensive discussion regarding her condition and prognosis. The patient is fully aware of the limitations and realistic outcomes, yet remains motivated to pursue treatment aimed at both aesthetic improvement and structural reinforcement.
Her expectations are influenced by acquaintances who have obtained favorable results with similar technologies, which reinforces her motivation to proceed despite the complexity of her case.

My main concern is not only the superficial appearance of her skin, but also the lack of dermal adherence and compromised structural support, which may significantly limit the response to conventional rejuvenation modalities. For this reason, I am particularly interested in opinions regarding the most suitable bio-stimulator or bio-regenerator to help achieve meaningful structural improvement in such cases.

Initial Therapeutic Plan:
Given the extent of tissue laxity, prior surgical fibrosis, and reduced tissue integrity, I considered Endolift suboptimal as a first-line option, anticipating difficulty maneuvering the optical fiber through a highly detached and irregular subcutaneous plane.
Instead, I proposed an initial tissue conditioning protocol:

• Exion Microneedling (fractional RF) – face and neck, ×3 sessions

• Sculptra (poly-L-lactic acid) – face and neck, ×3 sessions, spaced one month apart

The patient has now completed her third session of both modalities. Despite good tolerance, visible improvement remains limited, likely reflecting the degree of baseline tissue deterioration.

Second-Phase Proposal:
I suggested progressing to a Fotona 4D laser protocol, combining non-ablative tightening and fractional Er:YAG resurfacing, paired with PRP and a biostimulatory filler (Ellansé).
The goal is to enhance the interface between the skin and deep tissues, improving their cohesion and biomechanical quality, to create a more favorable substrate for a potential Endolift procedure later on.

Discussion Points:
At this stage, I am concerned that, despite the stepwise approach, the structural benefit may remain limited due to the degree of dermal separation and chronic damage. The patient is fully informed of the severity of her case and the restricted potential for significant lifting, but I remain cautious about recommending further costly interventions without sufficient biological substrate for improvement.

Attachments:

• Baseline images and short video illustrating the degree of skin flaccidity and detachment.

Questions for Discussion:

1. What are your thoughts on the therapeutic sequence and the rationale for preconditioning before Endolift in this scenario?

2. Would you have approached this case differently, or chosen alternative biostimulatory or laser-based options?

3. Which bio-stimulator or bio-regenerator do you consider most effective in patients with such severe atrophic, detached tissue?

4. Have you observed meaningful structural improvements (beyond surface changes) with combined biostimulation and fractional technologies in similar cases of severe post-surgical flaccidity?

5. Any insights on predictors of response or practical contraindications for Endolift in cases with extreme dermal detachment and poor tissue adherence?