As the human face ages, it experiences an increased severity of wrinkles, loss of skin laxity, and repositioning of fat. The synergistic effect of these factors are the root concern of many patients. Elective surgical interventions, like the facelift, give patients immediate, significant, and long lasting outcomes that target the synergetic effect. However, these surgical interventions come at a cost. First, downtime of an elective surgical intervention can be approximately two weeks. Second, the cost of the procedure may range from $10,000 to $25,000. The cost of downtime and actual dollars creates a barrier to a large portion of patients who may benefit from these elective surgical interventions.

These barriers have given rise since the 1980s to non-surgical interventions like neuromodulators (e.g. Botox Cosmetic), cosmetic lasers (e.g. IPL), and hyaluronic acid fillers (e.g. Juvederm). Non-surgical interventions have had impressive growth but they have not matched the outcomes of their surgical counterparts (e.g. facelift).

Is it possible to produce significant lifting outcomes without the need for a surgical intervention? An effort to answer this question motivated medical researchers to develop procedures and techniques that aim to deliver outcomes without the need for surgical interventions.

1988 - Anti-Ptosis Technique

Dr. Marlene Sulamanidze introduced a protocol and technique in 1988 that used barbed sutures (common in wound closures) to provide patients with lifting outcomes without the need for surgery. The concept was to introduce a barbed suture under the skin which would anchor the lax skin and “stretch” it into place. This early technique was coined Anti-Ptosis (APTOS). Ptosis refers to the drooping of the eyelid. Therefore, APTOS aims to improve the drooping of the eyelid using the suture technique. APTOS uses a suture material made of blue dyed 2-0 polypropylene suture with opposing barbs. This technique was marketed under the name Featherlift. Although innovative, the technique failed to produce lasting outcomes because the suture anchored to soft tissues. Anchoring to soft tissues will give the immediate results, but fails to serve as a sturdy structure. Therefore, long lasting results are not achieved (Sulamanidze, Fournier, Paikidze, & Sulamanidze, 2002).

Isse Endo Progressive Facelift Suture Technique

Dr. Niccanor Isse recognized the benefits and concepts of the early Anti-Ptosis Technique and aimed to build on it. Therefore, he took the technique and altered two major components. First, he used a unidirectional suture. Second, Dr. Niccanor Isse used a hairline incision with the assistance of an endoscope. These differences allowed the suture to be placed deep enough to access sturdier tissues. Sutures anchored to sturdier tissues provided the long term results missing from the Anti-Ptosis technique. This technique was coined Isse Endo Progressive Facelift Suture Technique and is currently available and marketed under the names ContourThreads and ContourLifts (Hochman, 2007).

Hochman Modification Technique

Dr. Marcelo Hochman, a surgeon and researcher, developed a technique based on the Anti-Ptosis and Isse Endo Progressive Facelift Suture techniques. Hochman took both the Anti-Ptosis technique and Isse Endo Progressive Facelift Suture Technique and further modified it. The modification involves using the a small incision for both the entry and exit of the sutures and the tools used to place the sutures. Keeping the incision small and to a minimum allows for faster recovery times. The second modification that Hochman implemented is the use several barbed sutures positioned in a fanning pattern to create a kind of scaffolding under the target areas. This gives the target areas additional structure (Hochman, 2007).

Does suture lifting provide immediate, significant, and long lasting results with no downtime?

A study conducted by Dr. Marcelo Hochman in 2005 examined 70 suture lift procedures that focused on repositioning the fat malar pads (cheeks) and the jowl area (chin and jaw). Among the patients that underwent the procedure, less then 1% experienced extrusion of the suture. Unacceptable results, which include dimpling and poor results were seen in 3 procedures. After 12 months from the procedure, a large portion of patients experienced and maintained the lifting outcomes seen immediately after the procedure. Eight five percent (85%) of patients reported continued satisfaction of results even after 12 months (Hochman, 2007).

A study presented by the American Society for Dermatologic Surgery and conducted by Dr. Marlene Sulamanidze looked at 186 patients that underwent Aptos threads for facial drooping. This method was used to remove facial drooping of the cheeks and chin areas which is common area that worries the majority of patients as they experience aging. Poor results and or thread complications occurred in about 2.5% of the procedures. About 1% of the patients that underwent the the suture threading procedure had to undergo additional surgical intervention. These 1% patients expressed that they expected more radical changes after the procedure which prompted them to undergo surgical procedures (e.g. Facelift) (Sulamanidze, Fournier, Paikidze, & Sulamanidze, 2002).

What are the complications of Suture Lifting?

Dimpling

Dimpling is a complication where the skin appears to dimple at a point along the suture thread. The dimpling of the skin is due to the suture being placed too close to the surface of the soft tissues. Correction of dimpling includes removal of the suture and re-introducing the suture at a deeper plane.

Extrusion

Extrusion occurs when the ends of the barbed suture can be visible seen through the skin. If the barbed suture does extrude from its place, it will typically become visible at the entry and exit incisions. Correction of this complication involves trimming the suture and or dissolving the suture. If dissolving the suture is performed, then a new suture must be reapplied.

Foreign Body Reactions

Early techniques of suture lifting used sutures that were permanent and nonabsorbable. A review of these techniques has demonstrated that using permanent sutures may activate the body's immune system and reject the barbed suture. Complications involving foreign body reactions are resolved by removing the sutures. The latest suture lifting techniques use polydioxanone that are absorbable by the patient’s body. Using absorbable sutures prevents foreign body reactions but requires patients to undergo additional procedures every one year because the body absorbs the suture over time.

What should patients expect? Specialized suture lifting procedures may offer patients a solution for wrinkles, laxity, and overall aging of the face. Patient selection and counseling is important for positive results and patient satisfaction. Ideal patients are typically aged 40 - 55 and have moderate laxity of the cheeks and chin. Suture threading is ideal for patients who have well developed but drooping malar pads and are not interested in a more invasive surgical procedures. Patients must be willing to undergo maintenance treatments on a yearly basis for continued lifting outcomes. Patients unwilling to undergo yearly procedure are recommended a more long lasting and surgical intervention (e.g. facelift). Suture lifting should not be introduced as an alternative to surgical interventions such as a surgical facelift. Suture threading, in its current form, will not reproduce facelift outcomes.

Sources

1. Atiyeh, B. S., Dibo, S. A., Costagliola, M., & Hayek, S. N. (2010). Barbed sutures “lunch time” lifting: evidence based efficacy. Journal of Cosmetic Dermatology,9(2), 132-141. doi:10.1111/j.1473-2165.2010.00495.x

2. Hochman, M. (2007). Midface Barbed Suture Lift. Facial Plastic Surgery Clinics of North America, 15(2), 201-207. doi:10.1016/j.fsc.2007.02.002

3. Paul, M. D. (2008). Barbed Sutures for Aesthetic Facial Plastic Surgery: Indications and Techniques. Clinics in Plastic Surgery, 35(3), 451-461. doi:10.1016/j.cps.2008.03.005

4. Winkler, E., Goldan, O., Regev, E., Mendes, D., Orenstein, A., & Haik, J. (2006). Stensen Duct Rupture (Sialocele) and Other Complications of the Aptos Thread 5. Technique. Plastic and Reconstructive Surgery, 118(6), 1468-1471. doi:10.1097/01.prs.0000239604.69415.e6

5. Sulamanidze, M. A., Fournier, P. F., Paikidze, T. G., & Sulamanidze, G. M. (2002). Removal of Facial Soft Tissue Ptosis With Special Threads. Dermatologic Surgery,28(5), 367-371. doi:10.1097/00042728-200205000-00001

 

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AuthorOscar Bueno