Suture Facelift Techniques

27.1 Introduction

In recent years, minimally invasive facial rejuvenation procedures have become more popular. From 1997 to 2008, surgical cosmetic procedures in the USA increased by 180% whereas nonsurgical cosmetic procedures in the same period increased by more than 750% [1]. Patients seek minimally invasive treatments that do not require prolonged recovery periods, are low risk, inexpensive, and provide results that look natural. These include chemodenervation with botulinum toxins, soft tissue augmentation using injectable implants, laser skin resurfacing, and skin “tightening” using a variety of light and radiofrequency-based technologies [2]. Nonsurgical procedures improve hyperdynamic and static wrinkles, volume loss and skin surface imperfections but do not address ptosis of deeper tissues including the malar fat pad and the superficial musculoaponeurotic system (SMAS). Although an open facelift remains the gold standard for sagging skin, fat, and the SMAS in older patients, less invasive measures using various suture systems and designs provide a novel alternative for younger patients with early signs of aging. Suture facelift techniques are used as adjunctive measures during traditional open procedures [3] as a complement to less invasive open techniques [4], or as closed procedures without dissection through minimal incisions or punctures [5]. This chapter will focus on closed suture lifting techniques, commonly referred to as “thread lifts,”

P.M. Prendergast

Venus Medical, Heritage House,

Dundrum Office Park, Dundrum, Dublin 14, Ireland e-mail: peter@venusmed.com

for the face and neck using various suture materials and designs. These include barbed and non-barbed sutures, coned sutures, and slings using materials such as polypropylene, polytetrafluoroethylene, and polycaproamide sutures.

Although still in its infancy, the practice of suture lifting to improve facial contours, restore appropriate tissue projection, and redefine bony landmarks has been widely adopted. Despite this, published data on safety, efficacy, and long-term results remains scant [6]. Unfortunately, the furor and media-driven hype over suture lifts, touted as “lunchtime facelifts” or “1-hour mini-lifts,” often generate unrealistic expectations amongst potentially suitable patients, or sway patients who would best be treated with a conventional rhytidectomy into believing they can achieve similar results with a suture facelift [7]. Nevertheless, these innovative techniques should be embraced rather than discarded so that they can be further studied, improved and refined, and eventually find their rightful place in aesthetic surgery and medicine. In the author’s view, suture facelift techniques currently provide a “better alternative” to nonsurgical tissue tightening devices such as radiofrequency and infrared light for patients who would benefit from lifting mild to moderate ptosis, but they do not replace open facelift procedures for those with more severe ptosis or excessive skin laxity (Table 27.1).

27.2 Concept

The goal of any facial rejuvenation procedure is to restore the youthful appearance of the skin and facial features and create contours, proportions, and shapes that are generally perceived as being attractive. These include a gently arching brow in females,

Table 27.1 Advantages of suture lifting techniques

high, defined cheekbones, full cheek anteriorly with smooth lid-cheek junction, and a clearly defined jawline. Several classifications for facial aging have been proposed that describe senescent changes in the upper, middle, and lower thirds of the face as well as the neck [8]. Gravity facilitates the aging process by providing a vertically inferior vector for tissue that has lost elasticity, underlying structural support, or both [9]. Volume changes are usually involutional and are now known to occur both in the underlying bony skeleton [10, 11] as well as the soft tissues. In the forehead and temples, thinning of subcutaneous fat reduces the buffer between skin and the underlying hyperdynamic muscles of facial expression, resulting in horizontal and vertical forehead lines. As periorbital bony support decreases and tissues become lax, the brow drops to a horizontal position below the level of the supraorbital ridge, resulting in dermatochalasis. In the midface, the malar fat pad descends gradually from its normal position over the zygoma. This descent leads to several aging traits. As the fat falls away from the lid– cheek junction, the lower lid appears to lengthen and the infraorbital area above the cheek develops a crescent-shaped hollow or teartrough deformity. The nasolabial fold deepens as the malar fat pad superolateral to it drops. Further inferolateral descent of the malar fat pad accentuates the jowls and flattens the cheek superiorly. In the jowls, fat deposition rather than involution is typical and this reduces jawline definition characteristic of a youthful appearance. Aging in the neck begins with mild skin laxity and hypertrophy of the platysma muscle, which appears as vertical bands. This progresses to prominent sagging platysmal bands and horizontal folds, with varying degrees of submental fat accumulation and submandibular gland ptosis.

The rationale for treatment using suture facelift techniques is to reverse early signs of aging by lifting and suspending tissues that have begun to drop. By repositioning soft tissue in this way, not only are the sagging tissues lifted, but volume is also restored in important areas, such as the midface. Even a lift of 5–10 mm in the midface area restores the beauty triangle by changing the shape of the face from one that is rectangular to a heart-shaped one that is more pleasing and youthful. Suture techniques are not intended to correct more advanced signs of aging where significant skin laxity is present. Similarly, excessive fatty deposits in the face, submental area, and neck are not improved with suture facelift techniques alone, particularly when the overlying skin is tight. These problems require more aggressive measures such as rhytidectomy and lipoplasty.

Closed suture lifting techniques employ sutures of various types and designs to either loop around or “spear” subcutaneous fat or fascia and lift or suspend it in a predetermined vector. The author performs suture lifts under regional and infiltrative local anesthesia only without sedation. These minimally invasive procedures can be performed in an office-based setting, through minimal incisions or punctures, and allow a quick return to normal activities. They offer appropriately selected patients a natural-looking rejuvenation. For the physician, the learning curve is short and several hands-on workshops and preceptor courses are available throughout the world [12].

27.3 Patient Selection

The ideal patient for a suture facelift has mild ptosis of one or more of the following areas: brow, lateral canthus, malar fat pad, jowls, and neck. Even mild ptosis of these areas can produce a sad or sullen look and lifting by a few millimeters will change the overall countenance to a more pleasing one (Fig. 27.1). Visible tear troughs, flattened anterior cheeks, and deepened nasolabial folds are evidence of descent of the malar fat pads and all improve with suture elevation of the fat pads alone. Suture lifting of the face and neck are appropriate when there is interruption in the definition of the jawline and an increase in the cervicomental angle. Most suitable candidates are 30–45 years old, although the author has successfully treated patients