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Suture lifts
Introduction
The pattern of facial aging is hallmarked by several facets, including the loss of volume in facial fat pads and diminished skin elasticity. In the midface, these processes lead to deepening of the nasolabial fold and diminished anterior cheek projection, while in the lower third of the face, the result of the maturation process can result in jowling, blunting of the cervicomental angle, and an indistinct inferior mandibular border. Skin laxity and descended features in the face and neck are common presenting complaints in aesthetic practice and are issues for which many patients seek both surgical and nonsurgical management.
Nonsurgical approaches to rejuvenation are increasing in popularity and allow for patients to avoid surgery and the associated risks and necessary downtime. However, nonsurgical modalities are often limited in their ability to provide full correction, particularly when used independently. Volume restoration with dermal fillers is unlikely to correct the consequences of laxity (e.g., deepening nasolabial or marionette folds) without overfilling, and treatment with energy-based devices alone such as microfocused ultrasound with visualization (MFU-V) or radiofrequency is often insufficient for repositioning descended tissues. Until recently, viable nonsurgical tools for tissue redraping have remained an unmet need.
Soft tissue redraping with suture and thread-based technologies has a complex history in aesthetic medicine beginning in the 1990s, and has included multiple “false-starts,” including nonabsorbable sutures, which proved to be prone to migration or extrusion. Sulamanidze and colleagues first reported the use of barbed threads (Aptos nonabsorbable polypropylene sutures) in 1998 in Moscow, Russia, although several reports noted high complication rates with this procedure. , Several similar techniques have since been developed, such as Woffles Lift (not commercially available), another nonabsorbable polypropylene thread with bidirectional barbs on either side of a central clear phone that allows the thread to be folded on itself in the temporal fascia as a self-fixating loop, and Isse Thread lift, which required surgical dissection of the scalp and fixation of the unidirectional barbed sutures to the temporal fascia. Contour threads, polypropylene sutures with unidirectional barbs, lost U.S. Food and Drug Administration clearance for nonsurgical applications in 2007 because of patient complaints. For these nonabsorbable sutures, complications included palpable thread ends with pain, thread migration, infection/granuloma, skin dimpling/irregularities, as well as more serious complications such as Stensen’s duct rupture, nerve damage, chronic foreign body sensation, and scarring, which caused a decline in popularity and a growing need for alternative materials. Today, the large majority of sutures and threads used in clinical practice for cosmetic purposes are entirely absorbable and do not require incisions or fixation to the fascia. Absorbable threads are made of polydioxanone, and absorbable sutures are made of poly-L-lactic acid and poly-L-glycolide (PLLA/PGLA). These nonsurgical devices are placed in the subcutaneous tissue where they mechanically support tissue and stimulate collagen. Because of their minimally invasive nature, biocompatibility, improved safety profile, and ability to address tissue descent, threads and sutures are increasing in popularity for facial and neck rejuvenation.
| Manufacturer | Thread Material | Thread Type | Arrangement of Supportive Structure | Longevity |
|---|---|---|---|---|
| NovaThreads | Polydioxanone (PDO) | Smooth (monofilament or braided) | NA | Volume returns to baseline by 18 months |
| NovaThreads | PDO | Barbed | Bidirectional | Lift returns to baseline by 1 year |
| Mint | PDO | Barbed | Bidirectional, helical | Lift returns to baseline by 1 year |
| Silhouette InstaLift | PLLA/PGLA | Cones | Bidirectional | Retreatment generally required at 18 months in the mid- and lower face and at 9 months in the neck |
Background information
Differentiating thread and suture technologies
Absorbable threads and sutures may be categorized based on construction as smooth (monofilament or braided), barbed, or cone-based threads. Smooth threads are placed in the subcutaneous layer, often in a mesh pattern, for the primary purpose of stimulating collagen production. These threads are not intended to lift the tissue, but rather provide improved skin quality and texture over time via the induction of neocollagenesis. In contrast, both barbed and cone-based technologies are designed not only to stimulate collagen but also to engage ptotic tissue for the purpose of lifting. Within the United States, all commercially available threads are made of either polydioxanone (PDO; Nova Threads and Mint Threads) or PLLA/PLGA polymer (InstaLift, Suneva Medical, Inc, Irvine, CA). Both PDO threads and absorbable suspension sutures achieve their effect through the dual mechanism of lifting and collagen stimulation; however, the efficacy of the overall treatment can be shaped by their differing properties, described later.
Mechanical lifting capacity
The construction of barbed threads differs from that of PLLA/PLGA absorbable suspension sutures in a number of ways. In barbed threads, the barb is created either through molding or cutting into the suture. While molding is thought to be less likely to compromise the integrity of the thread, both give rise to a leaf-like structure, which is intended to support descended tissue. Barbs may be unidirectional, bidirectional, or multidirectional, depending on the product. In contrast, the mechanical capacity for lift in absorbable suspension sutures is provided by bidirectional cones, held in place by intercalated knots ( Fig. 7.1 ). The cones of the absorbable suspension suture are unique in that they are designed to work in opposition to one another: on the superior side of the suture cones are placed in more fibrous tissue where they serve as anchors, while the cones on the inferior side are placed in more mobile tissue to provide lift and support to redraped tissue. From a mechanical perspective, cupped structures, such as those present in cones, provide significantly greater resistance to slippage than barbed structures, an observation reflected in the clinical performance of available thread and suture technologies. In addition, the distribution of the supportive structures in absorbable suspension sutures make them a preferred modality when the primary aesthetic need is tissue redraping. For applications such as addressing facial asymmetry (or palsy), or maintaining postsurgical results, the mechanical capacity of the suture is of particular importance.
Collagen stimulating capacity and biocompatibility
Both PDO and PLLA/PLGA have been shown to stimulate collagenesis; however, only the biocompatibility and biostimulatory activity of PLLA/PGLA has been established histologically in humans, both as a filler and when used as a suture. The collagen stimulating potential of PDO has been reported in several animal models, , where it appears to be similar to that of PLLA. However, to our knowledge, no human histology studies have been done of PDO threads, either in isolation or as part of a comparison with absorbable suspension sutures.
Versatility
Absorbable suspension sutures are also a versatile modality that can be adapted to individual patient needs. Available in three suture configurations (8-, 12-, and 16-cone), the authors’ experience is that the 8-cone suture is most often used to treat the face and upper neck. The 12-cone suture is typically used for treatment of larger surface areas in the lower neck or in larger faces to increase the purchase of recruited tissue.
Together, the long history of PLLA/PGLA use in both medicine and aesthetics confirmed biocompatibility and biostimulatory activity of PLLA/PGLA, and higher mechanical supportive capacity of absorbable suspension sutures make them one author’s (SMS) preferred method of nonsurgical management of laxity in the face and neck. Notably, hyperdilute biostimulatory fillers have emerged as a way to improve skin quality and volume, providing an alternative approach to smooth threads for aesthetic improvement and biostimulaiton. The choice to lift ptotic tissue with either biostimulatory fillers or threads will likely be based on cost and patient/clinician preference.
Absorbable suspension sutures are approved for use in the midface, but off-label use in the lower face and neck is both common in clinical practice and has been reported in smaller reports and literature studies. , In the midface, absorbable suspension sutures may be used to soften the nasolabial fold and can provide gradual revolumization because of stimulation of neocollagenesis by the suture’s PLLA. In the lower face, absorbable suspension sutures may be used to efface the marionette lines, provide definition along the jawline, and correct jowling ( ). Finally, absorbable suspension sutures may be used in the neck to correct tissue laxity.
Though the use of absorbable sutures for facial tissue suspension has been described, there seems to be a paucity of literature on addressing the neck and lower third of the face. Importantly, patient selection, a critical aspect of optimal treatment outcome for this anatomic region, is not well described. Detailed procedural information on treatment of the midface can be found within the literature , and is not discussed in detail here. Comfort with use of absorbable suspension sutures in the midface is a prerequisite for the treatment of the lower face and neck, as vector planning and procedural considerations are more complex.
Here, the authors present videos of optimal treatment planning and technique for treatment of the lower face and neck and share valuable lessons learned surrounding patient selection, complementary treatments, and case studies illustrating the nature of treatment outcomes.
Preprocedure considerations
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