CHAPTER 28 Suture suspension for brow and upper face

Introduction

Silhouette sutures in closed and open midface lifting

Over the past several years media buzz and patient demand have stimulated adoption of new surgical devices and techniques before optimal indications, patient selection, duration of effect, and complications are well known. Early adoption of new techniques can lead to patient disappointment and surgeon dissatisfaction, resulting in early abandonment of a procedure that otherwise has great value, although perhaps not for what it was originally by intended. Cosmetic surgeons are practicing in a competitive commercial environment in which patients are eagerly looking for new technology to satisfy desires for better, quicker, and less invasive approaches for facial rejuvenation. Product development results in newer and better devices as evidenced by the progressive development of Aptos sutures, Woffle sutures, Contour sutures, Isse sutures, and the new Silhouette suture (FDA approval, November 2006).

History

The concept of barbed sutures was first patented by Al Camo in 1964, followed by Fukuda in 1984 and Ruff in 1994. These innovators conceptualized barbed sutures for wound closure without tying knots, but did not discuss aesthetic applications. Suture soft tissue elevation was pioneered in the late 1980s by Sulamanidze who in 1999 obtained worldwide patents for the subdermal (Aptos) thread product. In 2000, Sulamanidze popularized the concept of barbed sutures in facial cosmetic surgery and devised the name APTOS (Anti-PTOSis – meaning antiptosis) for his system of treating facial descent. The technique for suture lift was subsequently published by Sulamanidze et al. in December 2001, with a formal series presented in 2002. Current variation of this technique includes Contour Thread, also referred to as Thread Lift or Loop Lift (Surgical Specialties Corporation, Reading, PA) and the APTOS lift or Feather Lift (Kolster Methods, Inc., Corona, CA).

Both barbed suture design and treatment have evolved since their introduction. The original APTOS suture was a multiple-dented suture meant to provide additional traction in tissue. This design was modified to be bi-directional, with the barbs oriented so that tissue would be retained in the central region of the suture without the need for anchoring at either end (Fig. 28.1A). It was then re-designed as a multiple-barbed polypropylene suture intended to provide traction and suspension unidirectionally (Fig. 28.1B). Approval from the FDA for the extended length unidirectional barbed suture was obtained by two different companies in 2004 and 2005, respectively. No other variant of the barbed suture has received approval, but a newer technology called the Silhouette suture (Figs 28.1, Fig. 28.2), which involves the use of clear, flexible, absorbable cones with accompanying small knots on a polypropylene thread, to allow for more effective soft tissue elevation, received FDA approval in November 2006.

Fig. 28.1 Silhouette suture.

Fig. 28.2 Multiple-barbed polypropylene suture. Straight needle 8-inch, 20 G, curved needle non-cutting circle 26 mm.

At the meeting of the American Society of Aesthetic Plastic Surgery in New York City in April 2007, the Surgical Specialties Corporation announced the withdrawal of the Contour Thread from the market, stating that all production had ceased and that all remaining inventory could be returned to the company. As of this date, no other company is currently manufacturing the helical barbed suture typified by the Contour Thread. The company has now focused its efforts on the wound closure market with the introduction of its line of bi-directional barbed sutures intended for deep and superficial wound closure, either primary or secondary.

Physical evaluation

Closed suture suspension of the brow

In the brow area there is questionable longevity because of the amount of tissue excursion that naturally occurs in this area, but it does provide a non-surgical alternative. The technique is best supplemented with Botox injections before the procedure and also continuing afterwards in order to relax the frontalis, corrugator, and lateral orbicularis muscles to decrease dynamic activity. In a presentation by Dr Nicanor Isse at the American Society of Plastic Surgery in New Orleans in 2005, his review of cases showed a 70% failure rate of brow suture suspension. Patients who might be considered good candidates would be those with mild bilateral brow ptosis with very modest expectations and accepting of an uncertain, but limited, longevity, and who wished to avoid a more extensive surgical procedure. Also, patients who have unilateral ptosis either due to facial asymmetry or neuropraxia of the temporal branch of the facial nerve, occurring after a previous surgery, may find this as a means of temporarily improving facial symmetry while awaiting return of nerve regeneration. In some patients who have a more pronounced soft tissue glide plane after open or endoscopic surgery, brow elevation with threads may provide a modest, but temporary, improvement, with a much less invasive procedure.

Suture suspension of the brow area is also very technique-dependent because of the thinness of the tissues and the amount of muscle activity. Threads can sometimes be used in combination with other surgery. This can be done either at the time of the surgery or secondarily. The sutures should be anchored to the fascia, and pre- and postoperative Botox treatment should be performed. Rather than a vertical direction of pull, a more superior lateral direction would help to smooth out frown lines near the eyebrows, help to prevent bunching, and sometimes help to decrease visibility of the suture with frontalis activity. As a stand-alone procedure, suture brow suspension is of questionable value because of its high incidence of rupture, extrusion, and palpability. Another good use for suture suspension area is its combination with the use of a brow Endotine (CoApt, Palo Alto, CA) forehead fixation device to further fine-tune brow position, especially in the presence of facial asymmetry or in patients in whom there is a loose soft tissue glide plane.

Closed suture suspension of the neck

Closed suture suspension of the neck has little, if any, application, due to the certainty of breakage of the threads, because of the wide excursion of the neck with repetitive twisting. One hundred per cent of the sutures in this area have ruptured over time.

Closed suture suspension of midface (closed melopexy)

In considering facial rejuvenation, there are four main areas where correction is required:

1. Soft tissue descent.

2. Volume loss.

3. Muscle induced lines.

4. Changes in skin texture, color and elasticity.

The closed midface melopexy only minimally improves tissue descent and volume loss and does nothing for muscle-induced lines or skin changes. Rating each of these areas on a scale of 1 to 4 with the highest score being 4, closed suture suspension provides for tissue descent at best at 0.5 and volume lost at best 0.5 (Table 28.1). It provides no effect on muscle-induced lines or skin changes, giving it a total of one out of four or 25%. For this reason, I call this the 25% rule or 25% lift, meaning that the closed melopexy with sutures provides a 25% improvement with the mini–open face lift, 25% of recovery, 25% of duration, and 25% of cost (Table 28.2). There is an important reason for the disappointing outcome. Suture lifting or suture traction by the threads lifts only the soft tissue which has not previously been dissected. For truly effective lifting to occur, tissue dissection needs to be performed so that tissues can be transposed and anchored under less tension, maintaining the lift until the tissue planes have healed in their new position. In summary, the results are not long-lasting, but they do provide a solution for certain unique situations.

Table 28.1 Effects of thread lift

Tissue descent	0.5
Volume loss	0.5
Muscle induced lines	0.0
Skin changes	0.0
25%	1 out of 4

Table 28.2 25% Rule

• 25% of mini open face lift

• 25% of recovery

• 25% of duration

• 25% of cost

The new Silhouette suture is stronger than the conventional barbed sutures, it stands less chance of breakage, and it interacts with normal tissues through surrounding collagen tissue formation for better results. The suture consists of a 25 cm long 3-0 non-absorbable polypropylene suture that is 50% thinner than the 2-0 used in the design of the barbed sutures. This decreases knot palpability and pain in the temporal area. Suture strength is maintained by avoiding oblique cuts in the suture, in order to create the “barbs” (30–50% loss of suture strength). Each suture holds 11 clear, flexible, absorbable hollow cones that allow for tissue growth inside and around the cones (co-polymer of glycolic acid and lactic acid) (see Fig. 28.2). An immediate anchoring effect is created by the cones. A delayed anchoring effect is produced by a series of knots created on the distal 10 cm of the suture, which is intercolated with the cones (Fig. 28.3). The knots control the position of the cones and create further anchoring of the soft tissue, in turn creating collagen deposition around and inside each loop of the knot. These sutures can easily and safely be removed after the cones are completely absorbed using a small microphlebectomy hook.

Fig. 28.3 A delayed anchoring effect is produced by a series of knots created on the distal 10 cm of the suture, which is intercalated with cones.

The co-polymer cones (Fig. 28.4) are soft and avoid the pinprick effects of the barbed suture. Their large size (1.0 mm × 2.5 mm) creates a strong grasping effect on the fibrous soft tissue. The cones are hydrophilic, resulting in absorption of water and in a softer feel. They generate more collagen formation, due to the chemical interaction with the tissues, as well as the physical design of the device. A stronger soft tissue support is the result. The cones are absorbed over 8–10 months, with 50% of the device volume being absorbed in approximately five months (Fig. 28.5).