Straight-Line Vector Planning for Optimal Results With Silhouette InstaLift in Minimally Invasive Tissue Repositioning for Facial Rejuvenation
July 2018 | Volume 17 | Issue 7 | Original Article | 786 | Copyright © 2018
Z. Paul Lorenc MD FACS,a David Goldberg MD JD,b Mark Nestor MD PhDc
aLorenc Aesthetic Plastic Surgery Center, New York, NY; Department of Plastic Surgery, Lenox Hill Hospital, New York, NY bSkin Laser & Surgery Specialists of NY/NJ; Icahn School of Medicine at Mount Sinai; New York, NY Fordham Law School, New York, NY cCenter for Clinical and Cosmetic Research, Center for Clinical Enhancement, Aventura, FL; Department of Dermatology and Cutaneous Surgery and the Department of Surgery, Division of Plastic Surgery, University of Miami Miller School of Medicine, Miami, FL
Background: Absorbable suspension sutures for tissue repositioning represent a minimally invasive approach to facial rejuvenation. With 2015 FDA 510(k) approval of Silhouette InstaLift™ (Sinclair Pharma, Irvine, CA), a completely absorbable device comprised of 82% PLLA/18% PLGA sutures and bi-directional cones, came the challenge of developing optimal technique for achieving effective, precise, and durable tissue repositioning. Here, the authors discuss the importance of straight-line vector planning (SLVP) and positioning of the suture perpendicular to the plane to be elevated in obtaining optimal results for tissue repositioning. Both the scientific underpinnings of SLVP are presented, along with detailed discussion of technique for suture placement in the mid-face, jawline/jowls, and neck. Methods: The authors are some of the earliest adopters of absorbable suspension sutures in the United States and have both used InstaLift™ sutures for tissue repositioning and facial recontouring in treatment of more than 500 patients and developed the principles of SLVP as a method to ensure optimal outcomes. Results: Patient case studies illustrating the importance of SLVP are presented. In over 500 patients treated within the authors’ practices since InstaLift approval there have been no serious adverse events and noticeable bruising has occurred in less than 5% of patients. Results of repositioning and recontouring are evident for up to 24 months. Conclusions: Absorbable suspension sutures are a highly adaptable, non-invasive device for lifting and repositioning of descended facial tissue. Outcomes are dependent upon proper technique, including SLVP. J Drugs Dermatol. 2018;17(7):786-793.
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Facial aging may be apparent through the appearance of wrinkles, volume loss, and sagging. For sagging in particular, reductions in elastin and the supportive capacity of collagen result in greater skin laxity and volume loss.1 Further, thinning of connective tissues in conjunction with involution of ligament bony attachments and age-related decrease in ligament stability2,3 contribute to the sagging and descent of facial features.Several products have been introduced over the past two decades in response to the need for non-surgical approaches to soft-tissue repositioning and suspension. Between 2001 and 2006, a variety of permanent and absorbable barbed sutures (originally developed for wound closure and tendon repair) were adapted for facial rejuvenation.4-6 However, early results were short-lived, and several difficult-to-correct complications emerged,4,5,7,8 ultimately leading to withdrawal of the 2004 FDA approval for Contour Threads (Surgical Specialties Corp., Reading, PA) in 2007.In 2006, the FDA approved Silhouette Lift (Kolster Methods, Inc., Corona, CA) a device for use in facial surgery. This suture is permanent, with resorbable, unidirectionally oriented cones made of poly-L-lactic acid (PLLA) and glycolide polymer (PLGA) and is held in position by knots along the length of the suture. These cones serve to fix overlying skin in a lifted position and promote ingrowth of fibrous tissue around the main suture and knots via the same foreign body reaction and low-grade inflammatory response initiated by PLLA/PLGA.9 Despite high patient satisfaction, the required technique for placement (open dissection of the deep temporal fascia in the temporal region, mastoid fascia in the retroauricular area, and periosteum in the scalp for suture fixation), along with the permanent nature of the suture material, limits the utility of this treatment, leaving clinicians without a viable non-surgical approach to tissue suspension.The FDA granted 510(k) approval for Silhouette InstaLift™ (Sinclair Pharma, London, UK) in 2015. Silhouette InstaLift differs from its predecessor in two important respects: both the