Does Skin Bunching From Sutures Flaten

Abstruse

Self-retaining barbed sutures, innovations for nonsurgical facial and neck rejuvenation, are currently bachelor every bit short APTOS threads or long WOFFLES threads. The author uses APTOS threads for malar rounding, facial tightening and firming, and uses WOFFLES threads equally a sling, suspending ptotic facial tissues to the business firm, dense tissues of the temporal scalp.

Nonsurgical facial rejuvenation is the Holy Grail of aesthetic surgery and has stimulated a decades-long, if not centuries-long, search for innovative techniques. Persistence of results and rubber have been 2 major obstacles in achieving this goal.

Facial rejuvenation has traditionally included a face elevator, neck elevator, and upper and lower blepharoplasties. These procedures involve significant recovery time, potential complications, and results that may not restore patients to the way they looked when they were younger.

Treatments for eradicating wrinkles, such as Botox (Allergan, Irvine, CA), narrowing lower facial width (Botox facial sculpting), and improving facial sheen (Mesobotox); synthetic fillers for volumetric restoration or enhancement of facial contours; and a wide variety of no downtime facial treatments ⁱ have brought us closer to achieving the instant gratification that patients want. However, what has eluded us is a safety and effective "lunch hour" procedure for elevating and redraping the soft tissues in an upward direction, with minimal or no patient downtime.

The polish suture elevations of Fernandes (oral personal communication, 2002), Graziosi, ² and Erol ^three provided elementary solutions to brow or midface pinnacle with little morbidity, but the results were unpredictable. Sutures tended to cut out too easily, and puckering and pleating of the surrounding skin were disturbing, resolving with a concomitant loss of lifting issue. Suture intermission techniques of Keller, ⁴ Sasaki and Cohen, ⁵ and De Cordier and Vasconez ⁶ have shown encouraging results only require some form of tissue dissection and belong in the surgical category because they have appreciable reanimation.

Woffles T. L. Wu, MD, Singapore, is a plastic surgeon.

In contempo years, barbed sutures take been proposed equally the method to reach a nonsurgical face lift. This technique has captured the interest of patients and surgeons worldwide. All the same, experience has taught u.s. that new techniques may sally, get popular, and and so apace fade into oblivion when they practise not live upwards to their promise or are replaced past newer and ameliorate technology. Here I will describe the electric current status of barbed sutures, with consideration equally to whether they will stand up the exam of time and achieve what they hope. Since 2002 I have had experience with more 200 APTOS and WOFFLES lift procedures using the WOFFLES threads (Kolster Methods Inc., Corona, CA).

Barbed Sutures

Barbed sutures, which are bidirectional and self retaining, currently exist in 2 primary forms: the curt APTOS ⁷ , ^viii or Featherlift thread and the long WOFFLES thread. ⁹–¹² A third variation, the Isse Endo APTOS thread, is a unidirectional not-self-retaining thread used in conjunction with an endoscopic confront elevator and, every bit such, belongs in the surgical category.

The APTOS threads are barbed monofilament polypropylene threads bachelor in #three-0 and #ii-0 sizes with lengths of ten to xiv cm. The WOFFLES thread is made of the same material and is available in the #two-0 size at a 60-cm length for optimal handling. APTOS threads accept also been reported on past Lycka et al, ¹³ who document its apply in several hundred patients.

The concept of spinous sutures was first pioneered past Alcamo in 1964, ^fourteen followed by Fukuda in 1984 ^xv and Ruff in 1994. ^xvi , ¹⁷ These innovators conceptualized barbed sutures for wound closure without tying knots merely did non discuss aesthetic applications. In 2000, Sulamanidze popularized the concept of barbed sutures in facial cosmetic surgery and devised the name APTOS (Anti-PTOSis) for his system of treating facial ptosis. In 2002, I devised the nonsurgical, self-retaining barbed suture sling to attain a more than direct and longer lasting soft tissue height. Leung and Pritt ¹⁸ have reported on the integrity of barbed sutures.

APTOS Threads

Designed to elevate the tissues and reach a face lift upshot, this system uses several brusque, bidirectional barbed sutures (up to 12 per side) inserted in a curved way into sagging, flabby facial areas, to cinch and elevate the tissues. The barbs on either side of the thread, oriented towards the heart, open and engage the soft tissues once the ends are pulled in opposite directions. This makes the threads self-retaining or locking. The process is simple to perform under local anesthesia, takes 10 minutes for each area (cheeks, jowls, brow, or neck), and recovery is swift.

I have noted positive and negative effects using APTOS threads.

Right thread placement is essential to reach the initial meridian and bunching of the soft tissues. If sutures are incorrectly placed, the skin becomes but puckered or may even get depressed.
The threads may be placed besides superficially and cause visible dimpling and tethering, or may be placed too deeply and accept piffling upshot.
The cinching of the tissues initially creates a volumetric restoration, most desirable in the malar mound, which appears rejuvenated one time it becomes fuller and elevated (Effigy 1). In other areas of the face up, such equally the brow and the jowls, such a bunching up of tissues is less desirable. However, with time, the APTOSed area flattens out, leaving firmer and tauter facial skin.
Although very footling persistent meridian is seen, facial tissues appear tighter, firmer, rejuvenated, and, importantly, patients seem happy with the results. I believe the improvement occurs because subsequent fibrous tissue product around the threads combined with the implanted threads act as a scaffold inside the soft tissue matrix. This fibrocollagenous reaction enhances the collagen matrix of the dermis and subcutaneous tissue. Correctly oriented APTOS threads take the effect of making the face announced sleeker and tighter.

Figure 1

A, Preoperative markings for APTOS malar rounding and elevation. B, Postoperative view after 24 hours.

I have performed 102 APTOS procedures (in 32 men and 70 women) in the last 2 years. In the first two procedures I performed (May 2002), I placed APTOS #3-0 threads in the cheeks and jowls. The results were not encouraging. Both patients complained that there was niggling event and I agreed. As a issue, I stopped performing the procedure until I was introduced to the Featherlift (#two-0) threads in December 2002. With the Featherlift threads, the cinching power was greater and a visible tissue elevation could exist seen initially without the barbs of the threads giving mode. With time, although the tiptop was lost, patients remained satisfied because they felt a tightening or firming in the areas that had been treated. In my experience, APTOS is less useful for confront lifting, perchance because there are no stable fixation points. Nonetheless, information technology remains a useful facial rejuvenation technique considering of its tightening and firming attributes.

APTOS Complications

The most significant issues have been palpability and extrusion of thread ends. Of 102 patients, at that place were 8 migrations, 5 infections/granulomas, and 11 palpable thread ends with pain. Five patients complained of dimpling and irregular waviness of the skin, which was caused by superficial placement. In all of these patients, APTOS threads had to be removed. A common complaint of patients who had undergone APTOS procedures with other surgeons was that their postsurgical advent was "strange," uneven, bumpy, unusually dimpled, or older. On examining these patients, I discovered that, invariably, the threads had been placed in directions and patterns that defied logic and reflected a lack of agreement of how the process works. Patients experienced removal of these threads with relief.

WOFFLES Elevator

This technique uses a specially designed threescore-cm thread that has a articulate 4-cm central zone, a 20-cm length of spirally arranged barbs on either side of this zone, angled towards the midpoint, and a smooth thread portion that is eight cm long. The WOFFLES thread is introduced into the sagging tissues of the face via a long, 18-gauge spinal needle and is doubled upon itself to form a sling whose ends emerge through the temporal scalp. The barbs of the thread engage the business firm, dense temporal scalp tissue and, therefore, finer suspend the sagging tissues of the face to the stable tissue of the temporal scalp.

The insertion technique in the WOFFLES lift is essentially the same regardless of where in the face or neck the lift is performed.

With the patient in the sitting position, first assess the caste of facial skin and soft tissue laxity and decide the correct vectors of break.
Determine the point of insertion and the signal of exit. Marker the 2 points and bring together them with a dotted line. Infiltrate local anesthesia with linocaine 2% and adrenaline 1:200,000 along the line and into any other vectors that you lot take designated.
Brand a pocket-size stab incision with a #11 bract to create an entry port at the point of insertion. Pass the long, 18-gauge spinal needle into this entry point, start subcutaneously and and then more deeply into the deep temporal tissues, and so emerge at the temporal scalp exit bespeak. From below, pass one end of the WOFFLES thread into the needle until the articulate, central zone is reached. Withdraw the needle, leaving 1 half of the thread in place and ane half outside.
Reintroduce the needle into the scalp 5 mm side by side to the first get out point and maneuver it in a retrograde management along a parallel path down the deep temporal tissues and out through the previous entry point. Introduce the remaining end of the thread through the tip of the needle until it exits from the scalp.
Withdraw the needle and pull on both ends of the WOFFLES thread, thus elevating the sagging tissue. The reverse angled barbs on the side of the thread prevent the tissues from dropping back to their original position. The point of greatest tension or suspension is over the primal articulate zone. Still, this tension is further distributed along the length of the spinous thread (compared with a smooth suture that just glides within the tissues and has a greater trend to "cut out" at the folded, central portion).
Tie the two ends together subcutaneously or cutting both ends of the thread flush with the scalp. Every bit many every bit five threads can be placed on each side of the face, each having a different vector to accommodate the unique needs of the patient. My current preference is to insert the threads through entry points just anterior to the hairline (Figure 2, A). In this way the pilus tin can easily disguise dimples, bruises, or the entry point itself, and patients tin can return to activity and social situations within a solar day or so. Inserting the threads more distally in the face (Figures two, B and C) leads to increased visibility of the entry points, dimples, and, therefore, to a longer downtime.

Figure 2

A, Preoperative markings for WOFFLES anterior hairline temporal-midface elevator. B, Preoperative markings for WOFFLES lift direct malar elevation. C, Preoperative markings for WOFFLES elevator jowl elevation.

Having performed 112 WOFFLES thread lifts (in 17 men and 95 women), I tin can conclude that the results simulate a traditional face lift. There is dramatic summit of the midface and jowls with smoothing and tightening of the peripheral face. Some folding and pleating of skin inevitably occurs above each entry point, necessitating more threads inserted superiorly to smooth out the skin folds. This results in lateral brow and center corner top. The exaggerated eye slant settles within ii to three weeks. In that location is a recurrence of virtually xxx% facial laxity inside 3 months, and and so the improvement remains stable upward to a twelvemonth subsequently (Figure iii). Several patients accept requested boosted thread insertion to raise the tissue peak.

Effigy three

A, Preoperative view of a 70-year-old woman. B, Postoperative view 1 week subsequently WOFFLES lift of the lateral brow, midface and jowls via inductive hairline placement of four WOFFLES threads on each side. Patient also received Botox to the glabellar and central forehead regions. C, One year afterward procedures.

Figure 4

A, C, Preoperative view of 37-twelvemonth-erstwhile woman. B, D, Postoperative view 1 week after WOFFLES lift of the lateral brow, midface and jowls via anterior hairline placement of 3 WOFFLES threads on each side. Patient also received Botox to the glabellar and crow'southward feet regions.

WOFFLES Elevator Complications

Nigh complications were minor, including knot palpability or knot exposure in the scalp, with or without a small granuloma (eleven patients), and dimpling at the point of insertion, requiring secondary pare release (5 patients). Most patients had some modest dimpling that faded with time. The exposed knots were hands removed and the thread cut affluent with the peel. Haemorrhage that occurred during the procedure could e'er be staunched with palmar compression. No patients experienced nerve problems. None of the threads accept been removed.

Current Applications

APTOS works better in patients who want subtle facial shape changes with priorities of midface and jowl tightness and firmness rather than tissue elevation. These patients do not want to alter their eye shape and are unprepared for any radical modify yet they nonetheless desire some improvement across Botox or fillers. APTOS is platonic for men.

With APTOS, I have non been able to accomplish persistent facial elevation except for the malar surface area. In the malar area, soft tissue bunching and tightening is about appropriate because this region looks more youthful with volumetric enhancement. The initial pinnacle achieved with APTOS, largely due to the bunching and concertina effect on the soft tissues, is undesirable in the forehead, lateral face, and jawline—areas that should appear polish and taut. The brow, which has little requite and is relatively adherent, is a difficult region to drag using APTOS sutures alone and appears to respond amend to the firmer pull of WOFFLES threads.

The WOFFLES elevator is capable of significant tissue elevation but invariably makes the eye more elongated and upwardly slanted, similar to a subperiosteal confront lift. The tightening consequence on the midface and jowls is significant and thus appropriate for patients desiring a truthful face lift issue who exercise non wish to undergo surgery with consequent downtime. These patients are prepared to merchandise a fast, predictable result for the longevity of a traditional open or endo face lift and might repeat the process in a few years or request additional thread insertion to start the aging process.

I utilise WOFFLES threads to drag the midface, brows, and jowls, smoothing the facial periphery and achieving facial tautness. I use the APTOS threads to circular and elevate the malar mounds besides every bit to firm upwards the jowl and cheek areas. I still use APTOS in the brow in selected patients who want very subtle elevations between ane to ii mm. In the neck, I use the WOFFLES threads equally a series of long slings spanning the mastoid fascia and passing under the cervicomental angle (Figures 2, C and v).

Figure v

A, Preoperative view of a 54-year-erstwhile woman. B, Postoperative view later WOFFLES lift to neck using five WOFFLES threads spanning the mastoid regions and passing beneath the cervicomental angle.

My preferred strategy is to utilise APTOS threads to round the malar mounds, providing volumetric enhancement and 3-dimensionality to the forepart of the confront, and the WOFFLES lift to elevate the midface, smoothen out the jawline, and flatten the peripheral face. Both techniques are ideal for patients who are either not fix or reluctant to undergo traditional open up techniques with consequent downtime.

Note: Dr. Wu receives royalties from the auction of WOFFLES threads. He has no financial interest in the manufacturer'due south or distributor's companies.

References

Facial Rejuvenation without facelifts: Personal Strategies. Regional Briefing in Dermotological Laser and Facial Cosmetic Surgery 2002, Hong Kong

September

thirteen-fifteen

2002

Browlifting with thread: The technique without undermining using minimum incisions

Aesth Plast Surg

1998

;

120

–

125

Brow suspension, a minimally invasive technique in facial rejuvenation

Plast Reconstr Surg

2002

;

109

2521

–

2532

et al.

Elevation of the malar fat pad with a percutaneous technique

Arch Facial Plast Surg

2002

;

–

Meloplication of the malar fatty pads by percutaneous cable-suture technique for midface rejuvenation: result study (392 cases, six years experience)

Plast Reconstr Surg

2002

;

110

635

–

654

Rejuvenation of the midface by elevating the malar fat pad: review of technique cases and complications

Plast Reconstr Surg

2002

;

110

1526

–

1536

Removal of facial soft tissue ptosis with special threads

Dermatol Surg

2000

;

367

–

371

Facial lifting with APTOS threads

Int J Cosmetic Surg Aesthetic Dermatol

2001

;

275

–

281

Facial Rejuvenation using APTOS and WAPTOS (the WOFFLES LIFT): A novel approach

13th International Congress of the International Confederation of Plastic and Reconstructive Surgery (IPRAS)

Sydney, Australia

September 10-xiv, 2003

The WOFFLES Elevator: a non surgical facelifting technique

Appearance Medicine Society of Australasia (AMSA) tertiary Annual Scientific Meeting

Wellington, New Zealand

March 17-20, 2004

Non surgical facelifting with the WOFFLES Lift

American Society of Aesthetic Plastic Surgeons (ASAPS) Almanac Coming together, Hot Topics Symposium

Vancouver Convention Eye, Vancouver, Canada

April xvi-21, 2004

Facial rejuvenation with a Suture Suspension technique: The WOFFLES ThreadLift

The Coupure Seminars 4th Edition: Controversies, Art and Technology in Facial Aesthetic Surgery

Gent, Kingdom of belgium

May half-dozen-7, 2004

The emerging technique of the antiptosis subdermal intermission thread

Dermatol Surg

2004

;

–

xiv

Surgical suture

U.Southward. Patent 3,123,077

1964

Surgical spinous suture

U.South. Patent 4,467,805

1984

sixteen

Insertion device for a barbed tissue connector

U.S. Patent five,342,376

1994

Barbed bodily tissue connector

U.S. Patent half-dozen,241,747B1

2001

eighteen

Spinous, bi-directional surgical sutures; in vivo forcefulness and histopathology evaluations

2003 Order for Biomaterials 29th Annual Meeting Transactions, #101