Expert Consensus on Achieving Optimal Outcomes With Absorbable Suspension Suture Technology for Tissue Repositioning and Facial Recontouring
June 2018 | Volume 17 | Issue 6 | Original Article | 647 | Copyright © 2018
Z. Paul Lorenc MD FACS,a Glynis Ablon MD,b Julius Few MD,c Michael H. Gold MD,d David J. Goldberg MD JD,e Stephen Mandy MD,f Mark S. Nestor MD PhD,g and Susan H. Weinkle MDh
aLorenc Aesthetic Plastic Surgery Center, New York, NY; Lenox Hill Hospital, New York, NY bUniversity of California, Los Angeles, CA; Ablon Skin Institute Research Center, Manhattan Beach, CA cFew Institute for Aesthetic Plastic Surgery, Chicago, IL; University of Chicago Pritzker School of Medicine, Chicago, IL; Northwestern University, Evanston, IL dGold Skin Care Center, Nashville; Tennessee Clinical Research Center, Nashville, TN; Vanderbilt University School of Nursing, Nashville, TN; Meharry Medical College, School of Medicine, Nashville, TN eSkin Laser & Surgery Specialists of NY/NJ; Icahn School of Medicine at Mount Sinai, New York, NY; Fordham Law School, New York, NYfSouth Beach Dermatology, Miami Beach, FL; University of Miami Miller School of Medicine, Miami Beach, FL gCenter for Clinical and Cosmetic Research, Center for Clinical Enhancement, Aventura, FL; University of Miami Miller School of Medicine, Miami, FL hBay Area Medical Complex, West, Bradenton, FL
important for optimal outcomes. Second, the 8-cone suture is preferred for all applications in the face. Third, for many patients in need of facial tissue repositioning in multiple distinct anatomical areas, a minimum of 4 sutures per side provides the needed mechanical benefit to achieve and maintain a meaningful degree of repositioning. While the technique should be tailored to suit the needs of individual patients, the authors generally recommend 3 to 4 sutures per side in the midface for moderate to severe mid-facial aging and 2 to 3 sutures in the midface for mild to moderate mid-facial aging (Figure 2).11 Common arrangements include 2 to 4 sutures in the midface with additional sutures placed as needed to address other areas such as jowling or jawline definition. A sufficient number of sutures ensures that the lifting capacity of the sutures is not surpassed by the amount of advanced tissue and that the mechanical burden on each individual suture is minimized, that the tissue to be repositioned (the zone of action) is evenly distributed over the sutures, and that the collagen stimulated by the PLLA/PLGA that comprises the sutures is sufficient to replenish volume and support both recontouring and ongoing tissue repositioning as the suture is absorbed. Undercorrection, either through placing a suboptimal number of sutures or failing to correctly advance the descended tissue, is not only detrimental to patient satisfaction but is a lost opportunity for use of an otherwise effective treatment.Though sutures should be placed to best support treatment goals, several canonical pathways of midface sutures are shown in Figures 2, 3, and 4. While early research on absorbable suspension sutures focused upon outcomes for on-label indications such as cheeks and nasolabial folds, the jowls and jawline definition should be considered part of a complete treatment plan.12 The contour of the jawline and the position and contour of the jowls strongly influence the impact of treatment in other parts of the midface and neck, and so should be included in patient evaluation.
Straight Line Vector Planning
For all applications, the issue of straight-line vector planning (SLVP) has evolved as a central principle for ensuring both efficient and enduring tissue repositioning. In order for the suture’s opposing cones to act in concert to provide support and lift, they must be oriented in a straight line (Z.P. Lorenc, MD, personal communication). Placement of the suture in a “U” or “V” formation diminishes the additive ability of the cones on each side of the suture to reposition tissue and dilutes the opposing forces of the bidirectional cones, increasing the likelihood of suture displacement and reducing the overall lifting capacity of the suture. In addition, placement of the suture so that it is perpendicular to the plane it is intended to elevate ensures that all of the supportive force exerted by the suture is directed towards repositioning the tissue it is intended to elevate, rather than diluted by an improper angle. For example, a suture intended to elevate the nasolabial fold should be placed perpendicular to the descended feature (Figure 2). Together, these principles of SLVP ensure that the lifting capacity of the sutures and clinical result are maximized. Once the aesthetic needs of the patient have been determined, the tissue that is to be repositioned, referred to here as the zone of action, is identified. The entry and exit points of the suture should be determined and marked with the patient in a full upright position so that the areas to be addressed are evaluated in their most natural state. During the procedure, the patient is reclined at a 45° angle for suture placement. In general, the exit point should be placed 1.5 cm past the point of action to allow for tissue movement (so that the inferior-most cone resides at the point of action). For the nasolabial fold, the inferior-most exit point is tangent to the lateral side of the of the nasolabial fold. For each suture, 1 entry site and 2 exit sites are marked, beginning with the points of action and distal exit site, then both the central entry point and proximal exit point are measured and marked along the planned straight-line vector.
Once the entry points and exit points have been marked, 1% lidocaine with epinephrine (1:100,000 dilution) is injected at the entry and exit sites. No lidocaine should be injected into the suture paths, as this may cause swelling and interfere with patient ability to sense pain, an important indicator that the needle is in the incorrect plane. To minimize patient discomfort, use a 32 gauge needle to administer 0.5 cc at each entry and exit site. To sufficiently dilate the entry point opening (exit points to not require an opening to be made in advance), insert an 18 gauge needle into the subcutaneous tissue perpendicular to the skin to a depth of 5 mm. Prior to inserting the suture, the suture should be grasped near the last cone on each side and pulled taut to tension, thus tightening the knots. Applying excessive tension to the suture by grasping the 2 needles can overstress the connection between the suture and needle, leading to breakage.Sutures are then placed using the 23 gauge, 12 cm needle appended to each suture. First, the needle should be inserted at the entry point in a perpendicular fashion, using the 5 mm depth gauge on the needle as a guide. Once the needle is at a 5 mm depth, the needle is turned at a 90° angle into the subcutaneous plane. The natural tendency is to withdraw the needle slightly prior to turning it; however, it is important to maintain the 5 mm depth so that the sutures are not placed too superficially. Once the needle is turned, it is carefully advanced toward the exit point, maintaining depth in the subcutaneous plane until the exit point is reached. The needle should pass easily through the subcutaneous layer without resistance: patient discomfort is an indicator that the needle is either too shallow or too deep and no longer in the correct plane. Should the patient show any signs of discomfort during placement, gently back the needle