sternocleidomastoid muscle. The needle is passed through the upper point, deeply at first to include the mastoid fascia or periosteum, and advanced in a sinusoidal path superficially under the skin toward the lower point. Before exiting from the lower incision, a deeper bite is taken to catch the posterior border of platysma. A USP# 2 polycaproamide suture is threaded through the needle and brought back to the retroauricular incision. Another pass is made, taking a parallel course to the first pass, and the end of the suture is passed from the lower to upper incision so that both ends of the suture exit behind the ear. The sutures are retracted enough to lift

a

b

the platysma and improve the contour of the neck, and tied. If there is dimpling of the skin at the lower puncture, an artery forceps tip is passed into the incision and gently lifted until the dimple is softened. Bunching of skin along the length of the suture improves without intervention.

27.4.3 Coned Sutures

Isse designed a polypropylene suture with regularly spaced knots along its length and small floating cones made of poly-L-lactic acid. He modified his earlier

c

Fig. 27.28 Lower superficial musculoaponeurotic system (SMAS) suture facelift. (a) Local anesthesia is infiltrated subcutaneously in front of the ear and under the temporal fascia above the ear. (b) Three stab incisions are made at points E, F, and G. (c) An artery forceps is used to penetrate the full thickness of the dermis at point E. (d) The curved needle is passed in the subcutaneous plane from point F toward point E. At the lower border of the zygomatic arch a deeper bite is taken to catch the zygomatic extension of SMAS. (e) The needle is advanced superficially and exits at point E. A USP#2 or USP#4 polycaproamide suture is threaded through the eye of the needle. (f) The needle

is withdrawn. (g) The needle is passed subcutaneously from incision G to point E and receives the distal end of the suture. (h) The needle is withdrawn so that a sling around the SMAS is created. (i) To anchor the suture superiorly, the needle is passed under the deep temporal fascia above the ear from point G to point F. Moving the needle in this plane should move the patient’s whole head. (j) The suture end is passed through the tip of the needle and the needle is withdrawn. (k) Both ends exit from the incision G. Lifting the sutures lifts the patient’s jowls and even neck as the SMAS is suspended. The suture is tied. (l) The incisions are lifted to bury the knot

Fig. 27.30 Neck lift using suture suspension technique. (a) Local anesthetic is infiltrated superficially along lines h to j. An incision using a #11 blade is made behind the ear (h) and over the anterior border of the sternocleidomastoid muscle (j). (b) A curved needle is passed from incision h toward incision j. Just before exiting at j, the needle takes a deeper bite to catch the platysma muscle (SMAS). (c) The needle exits and a USP#2 polycaproamide absorbable suture is passed through the tip. (d) The needle is retracted through point h. (e) The needle is

advanced again through the same puncture, taking a serpentine course through the superficial tissues, and exits at the distal incision to receive the end of the suture. (f) The needle is retracted again so that both suture ends exit at the retroauricular incision. (g) Retracting the sutures lifts the neck and improves the cervicomental angle. If there is a dimple at the inferior incision, this is released with an artery forceps. (h) The sutures are tied and cut. Slight bunching along the length of the suture is normal and resolves spontaneously in 2–3 weeks

barbed polypropylene suture for several reasons. Firstly, he felt a suture with knots would be stronger than a suture designed with cuts to create barbs, since the tensions applied to the barbs are prone to linear shredding where the barbs meet the body of the suture. Secondly, the cones are made of a material that incites an inflammatory response and stimulates collagen to secure the sutures over time. Finally, Isse believed the biomechanics of the cone design would be inherently stronger than most barbed sutures. Isse’s suture is currently marketed as the Silhouette Suture (Silhouette Lift, Kolster Methods Inc., Corona, CA). This is presented as a clear 3–0 polypropylene suture with 10 cones and multiple knots to prevent slippage of the cones and to hold them equidistant from each other within the tissues. A newer dyed polypropylene Silhouette Suture is also available containing 6 cones. The cones are made of poly-L-lactic acid and are absorbed over 8–10 months. There is a 20.3 cm 20G straight needle swaged to the distal end of the suture and a 26 mm halfcircle needle to the proximal end (Fig. 27.31). Included

a

b

Fig. 27.31 (a) Silhouette suture. A straight needle is swaged to one end of the polypropylene suture and a half-circle needle to the other. There are knots and cones along its length. (b) Absorbable poly-L-lactic acid cones