with Silhouette Sutures are 2 × 0.5 cm polypropylene mesh patches for anchorage to deep fascia. These coned sutures are particularly useful for midface and neck rejuvenation and can be performed under local anesthesia through minimal incisions [36]. There is evidence that coned sutures offer a more secure and stable lifting than most popular barbed sutures and are more resistant to structural damage in human tissues [37]. The author uses Silhouette Sutures alone or in combination with non-barbed absorbable sutures for midface, lower face, and neck lifting. The technique of midface and neck lifting using Silhouette Sutures is described below.

a

27.4.3.1 Midface

The patient is marked in the sitting position (Fig. 27.32). A line is drawn from the lobule of the ear to the modiolus. Sutures should not cross this line as animation and movement at the mandible may lead to disruption. The proposed path for the sutures is marked along the sides of the face. These markings reflect the appropriate lifting vectors, which are superior and superolateral. The inferior points mark the exit sites for the needles and start about 1 cm lateral to the nasolabial fold with 1.5 cm between each point. The vector lines converge in the temporal area, behind the hairline, where a 3 cm mark is

b

Fig. 27.32 Silhouette suture midface lift. (a) The patient is marked in the sitting position. The inferior points start about 1 cm lateral to the nasolabial fold. Subsequent points are spaced 1.5 cm apart. (b) A 2–3 cm incision is made in the temporal area behind the hairline where the vector lines converge. (c) The superficial temporal fascia is grasped and opened. (d) The shiny white deep temporal fascia is exposed. (e) A 1 × 1.5 cm piece of polypropylene mesh is cut and placed in the wound on the deep temporal fascia. (f) The mesh is sutured to the deep temporal fascia using a 4–0 nonabsorbable suture (g) The Silhouette suture is placed over the face to measure how many cones will span the malar fat pad and midface without extending into the upper face. This determines how many cones, if any, should be cut from the distal end of the suture after placement. (h) The

straight needle is passed just superficial to the superficial temporal fascia (STF) at the temporal incision, and through the subcutaneous fat of the cheek to exit at the first of the marked points. The STF splits into two leaves just inferior to the hairline and the temporal branch of the facial nerve travels through its layers. Staying superficial to the STF avoids inadvertent injury to the nerve. (i) The Silhouette suture is slowly pulled through the midface until the cones emerge from the inferior puncture. A number of cones can be cut from the suture at this time. (j) The suture is then cut distal to one of the knots and retracted to lift the malar fat pad. Each suture is tied to a neighboring one, and anchored to the deep temporal fascia and mesh, before closure in two layers

made for the incision site. After skin preparation and sterile draping, the marked areas are infiltrated with 2% lidocaine with 1:200,000 epinephrine. A 3 cm incision is made in the temporal area and diathermy is used for hemostasis. The superficial temporal fascia is exposed, grasped, and opened, exposing the shiny, white deep temporal fascia. A small 1.5 × 0.5 cm patch of polypropylene mesh is placed on the deep temporal fascia and sutured in place. The first Silhouette suture is measured externally over the cheek to determine how many cones are needed to run the length of the malar area. If all of the cones are left on the suture, some of the proximal ones may be visible under the thin skin of the temple area, or they may catch on the superficial temporal fascia when the suture is retracted. The author usually cuts three to four cones from the distal end of the suture after they exit at the inferior points. Cones are usually not removed if a Silhouette Suture with 6 cones is used. The suture is passed in the deep subcutaneous plane from the temporal incision, along the marked path, to the exit points. To do this, the straight needle enters the tissues just above the superficial temporal fascia under direct vision at the upper incision. The nondominant hand gently grasps the tissues over the needle as it passes through the temple and then malar fat pad, maintaining the same depth throughout. If the suture passes too superficially it may catch the dermis and result in irregularities. If it passes too deeply it risks injury to facial nerve branches, particularly the frontal branch as it passes between the layers of the superficial temporal fascia lateral to the eye. The needle should exit the skin at the inferiorly marked points perpendicularly to avoid catching the dermis. The straight needle is pulled through until the cones begin to emerge from the skin. At this point, one or more cones can be cut from the suture as outlined above, making sure not to pull through any cones that are to remain on the suture. The suture is cut just distal to one of the knots and retracted proximally to visualize the lifting effect on the tissues. The proximal halfcircle needle is passed through the superficial temporal fascia at the incision and then the needle is passed through both the deep temporal fascia and the anchored polypropylene mesh. The suture is not tied until all other sutures have been passed. Usually a total of four sutures are placed on each side of the midface. Once all of the sutures are in place, the half-circle needles

are cut from the proximal ends and each suture is gently lifted and tied to its neighboring suture. The temporal incision is closed in two layers. A gentle lift is sufficient to elevate the malar fat pad and even jowls and provide pleasing results (Fig. 27.33).

27.4.3.2 Neck

The coned Silhouette sutures are also used to lift mild to moderate ptosis of the neck (Fig. 27.34). If ptosis is coupled with significant submental and submandibular fatty deposits, lipoplasty combined with the Silhouette lift is more appropriate [34]. The author commonly uses ultrasound-assisted lipoplasty (VASER) combined with Silhouette sutures for this purpose. For the Silhouette suture lift, markings are made from behind the ear, along the neck under the line of the mandible to a point just proximal to the midline. Alternatively, this line can continue across the midline to a point just distal to it. A 1 cm retroauricular incision is made and the first suture is passed in the subcutaneous fat along the line of marking, and exits at the distal point. The author prefers to continue across the midline, so that the suture acts as a sling to support and lift the midline and improve the cervicomental angle. To bring the suture across the midline, the needle should first exit from a point just proximal to the midline. Before the needle exits completely from the skin, with the proximal end of the needle still under the skin, the needle is turned around so that the proximal end of the needle with the suture attached is now advancing toward the midline. It is advanced to a point just distal to the midline where a stab incision with a #11 blade is made to allow the blunt end of the straight needle to emerge. Once the suture is seen, it is cut from the needle and the needle is removed from the site. The suture end is pulled until the most distal knot on the suture is just visible. The suture is cut just distal to the knot and the proximal end of the suture at the retroauricular incision is gently retracted. The coned portion of the suture passes across the midline and provides a lifting along its length as well as a suspension of the submental area. Usually two sutures are passed on either side of the neck. The proximal ends of the sutures are secured to the mastoid fascia using the half-circle needles and tied to one another. The incision is then closed.