Fig. 27.4 Free-floating Aptos sutures with lifting vectors in the brow, malar fat pad, and jawline

threads (APTOS, Moscow, Russia), referring to the “anti-ptosis” procedure they perform. Aptos threads are available in 2–0 and 3–0 sizes and in various lengths. They are inserted into the subcutaneous tissues of the face in predetermined paths by threading them through an 18G spinal needle. Once the needle is removed, the suture remains in place with either end protruding from the skin. The soft tissue is then fashioned around the barbs, as slight traction is applied to each end. This has the effect of bunching up subcutaneous fat along the length of the suture and lifting the tissues in a vector perpendicular to the long axis of the sutures (Fig. 27.4). In this way, the malar fat pad can be made to lift superolaterally and project anteriorly, and the jawline can be made to straighten by lifting the jowls [17, 18]. After manipulating the tissue to create the

desired effect, the ends of the suture are trimmed and pushed under the skin.

The Happy Lift Double Needle (Promoitalia International Srl, Rome, Italy) is a newer polypropylene suture with bidirectional barbs arranged convergently. Unlike Aptos threads, there is a straight needle swaged to either end of the suture, obviating the need for a spinal needle for placement (Fig. 27.5). The barbs on Happy Lift threads are forked, presumably to improve purchase on the tissues (Fig. 27.6). There is little information in the literature on the use of these threads.

27.4.1.2 Anchored Bidirectional Barbed Sutures

In 2002, Wu devised a bidirectional barbed polypropylene suture to elevate soft tissue and anchor it to stable temporalis or mastoid fascia [19]. This 60 cm long thread has a 4 cm smooth central portion, a 20 cm section on either side of this with convergent barbs, and a smooth portion measuring 8 cm at either end. This so-called Woffles thread is passed subcutaneously along the chosen vector through an 18G spinal needle via two stab incisions. The needle passes from the inferior incision, through the subcutaneous fat, and bites the deep temporalis or mastoid fascia superiorly.

One arm of the thread passes from the inferior to superior incision via the spinal needle as far as the smooth central portion of the thread. The needle is then removed and reinserted through the superior incision to the lower one so the other arm of the thread can be passed in the same way. The needle is removed and the two ends emerging from the superior incision are lifted. This traction lifts the tissues at the smooth end of the thread and fastens the thread ends in the deep fascia via the downward facing barbs (Fig. 27.7). Both ends of the sutures are either cut flush with the fascia or tied to each other above it. Wu has developed second and third versions of this technique by inverting the “V” so that both free ends are in the face (Fig. 27.8), and interlocking two sutures to reduce the likelihood of “cheese-wiring” through the soft tissues at the point of maximal tension.

A second version of the Aptos thread by Sulamanidze employs the same bidirectional barbed suture as the original Aptos thread, but to either end a straight needle is attached. The two needles are lightly fused, enabling a single entry point. After the two needles puncture the skin as one whole, they are broken apart

Fig. 27.8 Woffles bidirectional suture in situ

and take two different courses. The point of anchorage using this technique is the point of entry: zygomaticocutaneous ligaments for a midface lift or temporalis fascia for an eyebrow lift.

Ruff, an American plastic surgeon, did extensive work and research on the use of barbed sutures for tissue approximation as well as facial rejuvenation [20]. In 2001, he obtained a patent for his

barbed sutures and insertion devices and formed Quill Medical. Working with Surgical Specialties Corporation, Ruff developed and marketed his barbed sutures for facelifting under the name Contour Threads. Although Angiotech has since acquired Quill Medical, and Contour Threads are no longer in distribution, they were used widely [21–23]. One version of Contour Threads, called Articulus, is an anchored bidirectional barbed suture. It consists of a 55 cm clear polypropylene suture with two 17 cm straight needles swaged to the ends. The central 5 cm of the suture is smooth, and adjacent to this there are two 15 cm barbed sections. The barbs are convergent toward the central portion. Each needle is attached to a 10 cm non-barbed section (Fig. 27.9). Placement of the Articulus is via a small incision in the temporal hairline. One of the needles is passed distally through the temporal incision, taking a bite of deep temporal fascia, and exiting in the midface lateral to the nasolabial fold. The second needle follows along a similar vector but exits more inferiorly. The thread ends are then held as the skin and fat pad are “walked up” the barbed suture until their elevated position provides

asatisfactory enhancement (Fig. 27.10). The barbs prevent slippage of the elevated tissues whilst the non-barbed central portion of the thread is anchored superiorly to the temporalis fascia. To prevent “cheese-wiring” this portion can be reinforced with

anonabsorbable Gore-Tex® pledget.

I-Lift Tensor Threads, a company based in Argentina and Spain, produce other anchored bidirectional barbed sutures called iLift sutures. These nonabsorbable, clear

Fig. 27.9 Articulus suture. This is a clear polypropylene suture with two 17 cm straight needles, a smooth 5 cm central portion, two 15 cm barbed sections, and a 10 cm non-barbed portion adjacent to each needle. The barbs converge toward the central portion

Fig. 27.10 Contouring following the insertion of the Articulus suture. The end of the suture is held as the tissues are pushed up along the barbs. The ends of the suture are then cut flush with the skin

Fig. 27.11 Bidirectional barbed polypropylene sutures with swaged needles from I-Lift Tensor Threads

polypropylene sutures vary in size for face, neck, and brow lifting (Fig. 27.11).

27.4.1.3 Unidirectional Barbed Sutures

The early bidirectional free-floating Aptos sutures, marketed in the USA as FeatherLift, were modified by Isse who designed a unidirectional barbed suture. The Isse Endo Progressive Facelift suture (KMI Inc, Anaheim, Calif), is a polypropylene thread measuring 25 cm with the distal 15 cm bearing 50 unidirectional barbs. Isse describes his technique of closed meloplication using six threads for each malar fat pad [24]. Through a temporal incision, a small area of dissection