is carried toward the zygomatic arch between the superficial and deep temporal fascia. A 20G 16 cm spinal needle is used to thread each barbed suture through the malar fat pad. Once the needle is removed, the sutures are lifted, trimmed, and secured to the deep temporal fascia by tying the smooth ends to a neighboring suture. The upward facing barbs engage the fibrofatty tissue of the malar fat pad and elevate it to a more youthful position. This also reduces the appearance of the tear trough, nasojugal fold, and softens the nasolabial fold.

Contour Threads (Surgical Specialties Corp., Reading, PA) were pioneered by Ruff and patented in 2004. The original and most widely used design is 25 cm, 2–0 polypropylene and contains helicoidally arranged unidirectional barbs along its middle 10 cm. On one end there is a half-circle needle for anchoring to fascia and on the other a 7-in. taperpoint straight needle for thread placement (Fig. 27.12). The straight needle is passed in a serpentine course through small stab incisions in the scalp or behind the ear and exit at the brow, lateral to the nasolabial fold or near the midline of the neck. The straight needle is then removed and the superior end of the thread is secured by suturing it to the fascia. With the patient in the sitting position, the distal end of the suture is held and the tissues are pushed up along the cogs to lift and contour the brow, midface, or neck. Finally, the distal ends of the sutures are cut flush with the skin. Despite being the most widely used barbed suture suspension technique in the USA, there is limited data on their efficacy and longevity [21].

The Happy Lift™ Anchorage sutures (Promoitalia International Srl, Rome, Italy) provide a similar method of suspension to Contour Threads, although

Fig. 27.12 The Contour Thread. A 25 cm, 2–0 polypropylene suture with helicoidally arranged unidirectional barbs along its middle 10 cm. On one end there is a half-circle needle for anchoring to fascia and on the other a 7-in. taperpoint straight needle for thread placement

Fig. 27.13 The Happy Lift sutures have ten regularly spaced barbs per 1.6 cm of barbed portion

differences exist. These include a greater barb density on Anchorage sutures (10 barbs/1.6 cm) compared to Contour Threads (7 barbs/1.6 cm) and a different barbmorphology (Fig. 27.13). Happy Lift™ sutures are now also available in both nonabsorbable polypropylene and slowly absorbable polydioxanone.

27.4.2 Non-barbed Sutures

Bukkewitz described the first suture suspension lift for cosmetic enhancement in 1956 [25]. He used a strip of nylon inserted subcutaneously, to retract and improve a ptotic buccolabial fold. Starting in 1966, Guillemain, working with Galland and Clavier, started lifting all areas of the face by passing tendons or nylon into the tissues with a Reverdin needle and in their 1970 publication gave the technique the term “curl lift” [26]. Since then, other materials used to sling and suspend drooping tissues include polypropylene (Prolene), expanded polytetrafluoroethylene (Gore-Tex®), and polycaproamide (Polycon).

27.4.2.1 Nonabsorbable Non-barbed Sutures

Mendez Florez revisited Guillemain’s curl lift technique and designed a straight double-bevel needle to pass the polypropylene suture into the tissues (Fig. 27.14) [26]. A small puncture is made in the cheek or brow and another one behind the hairline. The straight needle

Fig. 27.14 Double-bevel needle used for curl lift

passes through the lower incision and exits via the one in the scalp to receive one end of the thread. Then the thread is retracted back into the wound to a point just cephalad to the inferior puncture. Here, the needle is rotated 180º and tunneled once again toward the scalp incision, just parallel to the first passage. The other end of the thread exits and the two ends are lifted and tied. This is a simple, quick technique to lift subcutaneous fat but the smooth inelastic polypropylene suture tends to cut through the soft tissue at the point of lifting and results are short-lived.

a

Erol and Hernandez-Perez described simplified suture suspension techniques to elevate the brow using nylon and polypropylene, respectively [27, 28]. Small punctures are made at the hairline and at the level of the brow to allow passage of the sutures in the subcutaneous plane using a needle (Fig. 27.15). In Erol’s technique, the brow is suspended in the elevated position it assumes when the patient lies supine. Following infiltration of lidocaine 2% with 1:200,000 adrenaline, four stab incisions are made using a #11 blade, two directly above the lateral brow and two at the temporal hairline. A 4-0 nylon suture is passed from the medial to lateral brow incisions and the needle is then cut from the suture. Then an angiocatheter is passed subcutaneously from the lateral hairline incision to lateral brow incision and the end of the suture is passed through the eye of the catheter. The angiocatheter is withdrawn, bringing the suture out through the lateral hairline incision. The same maneuver is performed for the medial end so that both ends are exiting from the hairline incisions. Finally, the angiocatheter is passed from the medial to lateral incisions to bring the suture to the

b

medial incision. A knot is made to hold the eyebrow in position so that it does not drop inferiorly when the patient stands upright. Hernandez-Perez uses 3–0 polypropylene and a Keith needle to lift the brow in a similar manner and proposes that the loose tissues of the lateral brow, the undermining effect of the Keith needle, and the postoperative fibrosis that occurs along the sutures are enough to hold the brow in place without cheese-wiring. These brow lift procedures require superficial passage of needles, just under the skin, to avoid injuring the temporal division of the facial nerve where it passes about 2 cm above the lateral brow.

For midface rejuvenation, permanent sutures or slings elevate the malar fat pad without the need for long incisions, undermining, or dissection [3]. Sasaki describes his technique using either permanent CV-3 expanded polytetrafluoroethylene (Gore-Tex Inc, Flagstaff, AZ) or 4–0 clear Prolene sutures. The suture system used consists of a CV-3 Gore-Tex suture, a 3–0 braided Vicryl suture, a 3 × 8 mm Gore-Tex anchor graft, a second 4 × 4 mm anchor graft, two 10 cm Keith needles, and a 4–0 dyed Prolene guide suture (Fig. 27.16). Two stab incisions using a #11 blade are made along the nasolabial fold and a 1.5 cm incision is made in the temple 1 cm above the hairline. The first Keith needle with suture slings attached passes through the upper incision near the nasolabial fold and travels subcutaneously, through the malar fat pad, and exits from the temporal incision. The second needle passes through the same incision at the nasolabial fold but in a course parallel to the first needle and also exits through the incision behind the hairline. Then the

braided Vicryl suture is used like a gigli saw to cut through any dermal attachments at the nasolabial puncture site before the Gore-Tex sling and anchor graft are pulled under the skin through the puncture. The dyed Prolene suture is used to guide the anchor graft into place, or to retrieve the graft if it does not lie correctly. Once the Gore-Tex sling is in place and the malar fat pad is suspended adequately, the Vicryl and guide sutures are removed and the Gore-Tex ends are secured by passing them through the second 4 × 4 mm anchor graft and suturing them to the deep temporal fascia using a French-eye needle (Fig. 27.17). This technique can also be performed during open procedures, or with some dissection along the deep temporal fascia to create a pocket anteriorly past the brow [29]. Yousif describes his technique using expanded polytetrafluoroethylene (Gore-Tex MycroMesh, W.L. Gore and Associates, Flagstaff, AZ) to lift the malar fat pad in a vertical vector, although this is a true sling and not a suture and is performed as an open procedure [30].

The Aptos Needle, invented by Sulamanidze, consists of a smooth non-barbed polypropylene suture attached to the middle of a double-pointed needle (Fig. 27.18) [16]. Midface elevation is achieved using the suture to loop around the tissues to lift them in different superior vectors. The double-point allows passage of the needle in a loop without the need to completely exit the skin so that the suture remains in the same plane throughout its course. A single incision need only be made and the sutures are anchored to the periosteum of the lateral or inferior orbital rim (Fig. 27.19). A similar longer Aptos Needle is used to