Fig. 27.18 Aptos needles are designed to pass through tissues without the need to exit completely. This keeps the suture in the same plane throughout its course

rejuvenate the neck. For this, an incision is made in the retroauricular area and a 2–0 Prolene suture is placed in the mastoid fascia as a holding suture. By passing the long Aptos Needle from one retroauricular incision to the contralateral side, without completely exiting the skin as above, the suture is brought from one side to the other subcutaneously and functions as a sling. Each end of the suture is tied to the holding sutures, securing them to the mastoid fascia. More than one suture can be placed in this way until the tissues are lifted and the cervicomental angle is restored. Giampapa described a similar suture suspension technique to improve the cervicomental angle using Prolene in combination with liposuction and partial platysmaplasty through a submental incision [31].

27.4.2.2 Absorbable Non-barbed Sutures

Serdev, a Bulgarian cosmetic surgeon, improved upon Guillemain’s original and Mendez-Florez’s revised curl lift techniques by using slowly absorbable non-barbed semi-elastic polycaproamide sutures to lift moveable tissues and secure them to stable structures such as deep fascia or periosteum [32–34]. Using curved suture-passing needles (Fig. 27.20), the braided, antimicrobial sutures are passed through the platysma of the neck, the SMAS of the mid and lower face, the malar fat pad, and the superficial temporal fascia of the upper face. These tissues are gently lifted and suspended by passing the suture ends under the mastoid fascia, periosteum, or deep temporal fascia. These suspension techniques improve the cervicomental angle and definition of the jawline, reduce the appearance of jowls, elevate the malar fat pad, and lift the corner of the eyes and tail of the brow (Fig. 27.21). There are certain advantages of Serdev’s techniques. The propensity of the sutures to “cheese-wire” through the tissues is less because the SMAS, and not just subcutaneous fat, is lifted. The braided sutures also yield somewhat to movement due to their elasticity. Using special needles, the sutures are anchored to deep fascia or periosteum through tiny punctures only, obviating the

a

b

Fig. 27.20 (a) Curved suture passing needles for percutaneous superficial musculoaponeurotic system (SMAS) lifting techniques. (b) Braided anti-microbial slowly absorbable polycaproamide sutures are used to lift and anchor moveable tissues to stable ones

need for incisions or skin closure. The polycaproamide sutures absorb over 2–3 years, an obvious advantage for suture lifting where subsequent procedures are likely as the aging process continues. These simple but effective suture suspension techniques will now be described for the upper, mid, lower face, and neck.

Upper Face

The suture facelift technique in the temporal area provides a subtle but important rejuvenation of the

upper face by lifting the tail of the eyebrow, the lateral canthus, and the upper cheek (Fig. 27.22). In the periorbital area, elevation of soft tissues by 1–3 mm provides noticeable rejuvenation (Figs. 27.23 and 27.24). Markings are made at the proposed incision points. The first is along a line drawn perpendicular to the tail of the eyebrow, just behind the temporal hairline. A second point is made just behind the hairline 4–5 cm inferior to the first point. Two further points are made superior to the first points, along the desired vector lines of lift. One of these points should be along the superior temporal crest line where the deep temporal fascia attaches to periosteum. The hair is tied or retracted to expose the skin at the marked points. After skin preparation and sterile draping, local anesthesia using lidocaine 1–2% with 1:200,000 adrenaline is injected along the proposed path of the suture subcutaneously between the lower two points, on the periosteum between the upper two points, and under the superficial temporal fascia and above the deep temporal fascia between each upper and lower point. The superficial temporal fascia is a continuation of the galea over the frontalis muscle and the SMAS of the middle and lower thirds of the face. Stab incisions using a #11 blade are made at the marked points. The curved needle is passed from the upper medial incision to the lower medial incision, under the superficial temporal fascia but above the deep temporal fascia. To find this plane, lift a tuft of hair above the path of the needle and pass the needle deeply. There should be a thick layer of tissue covering the needle following passage, but it should not be so deep that the patient’s head rocks when the needle is moved. This indicates that the needle has passed under the deep temporal fascia. Once the needle tip exits the inferior point, a USP #2 polycaproamide sutures is passed through the eye of the needle and the needle is withdrawn. Next, the needle is passed in the superficial subcutaneous plane from the lower lateral incision to the lower medial incision and the suture end is threaded through the needle’s eye and brought to the lower lateral incision. The suture is above the superficial temporal fascia along this line. Then the suture is brought from the lower lateral to the upper lateral incision under the superficial temporal fascia as before. Finally, the needle is passed into the upper medial incision, taking a bite of periosteum and deep temporal fascia along the superior temporal fusion line, and exits from the upper lateral

Fig. 27.22 Upper face (temporal) SMAS lift using slowly absorbable polycaproamide sutures. The superficial musculoaponeurotic system (SMAS) is called the superficial temporal fascia (STF) in the temporal area and the galea aponeurotica medial to this over the forehead. (a) Four points are marked as shown and stab incisions using a #11 blade are made. One of the superior incisions (B) is made along the superior temporal crest line. (b) The curved needle is passed under the STF (above the deep temporal fascia) from point B to A. (c) A USP#2 or #4 polycaproamide suture is passed through the eye of the needle and the suture is brought back from point A to B. (d) The needle

is passed from point C to A in the superficial subcutaneous plane (above STF) and the suture end is threaded through. (e) The suture is brought to point D under STF as before. (f) Now both ends of the suture are exiting at the upper incisions. (g) The needle is passed deep into point B until it reaches periosteum. (h) A deep bite is taken, underneath the deep temporal fascia, and the needle receives the suture end at point D. (i) The needle is retracted so that both ends exit at point B. The sutures are gently lifted and tied. This lifts the STF, tail of the brow, and upper face. The suture is cut and buried by applying traction to the puncture site with the tip of an artery forceps

incision. The suture is brought from this incision to the upper medial one so that both ends exit from the same incision. The suture ends are lifted gently to elevate the superficial temporal fascia (temporal SMAS) along the hairline, and elevate the tail of the

brow and upper face. The suture is tied and the incision points, if inverted or tethered down, are released using the tip of a mosquito. The incisions heal quickly by secondary intention. A small amount of bunching of skin is usual along the hairline but this