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 © June 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

up until it is in the correct plane. A needle cap may be used to catch the needle as it passes through the exit point. Once the tract has been created, the suture must be pulled through from the entry point. Slight counter traction on the opposite side of the entry point from the direction of needle travel permits the cones to easily pass through the entry point. When pulling the suture into position, it is important that the tension applied to the suture be directly in line with the needle tract. Otherwise, the tension can act as a lever and cause the cones to “catch” on the dermis. Insert the needle appended to the other side of the suture through the same entry point, following the direction of the initial needle tract until the 5 mm depth mark is reached. It is important to place the needle in the same entry point in order to avoid a dermal bridge at the entry site where the suture is too superficial. Either side of the suture may be placed first, depending on the preference of the physician. Once the suture is in place, tension the suture on both sides to ensure there is no depression at the entry site. When the suture is tensioned, the skin will remain evenly taut, and there should not be dimples at any point along the length of the suture, as dimples are an indication that the depth of the suture is varied, and cones are caught on the dermis. Dimples at the entry point indicate a small skin bridge resulting from needle entry at slightly different points. Any observed dimples at the entry point may be dissipated by gentle massage directly over the affected area or subcision using the 23 gauge needle if necessary. After proper placement is confirmed, apply tension to the inferior potion of the suture, and grasping the suture itself rather than the needle, begin the tissue elevation process by advancing the tissue in the zone of action over the lower cones, engaging the cones. Then, apply sufficient tension to the superior aspect of the suture to further and fully elevate the tissues in the zone of action to the desired achieve adequate repositioning may seem to be an overcorrection, this level of tissue elevation is central to obtaining optimal results and is a valid aspect of treatment. If at any time during the procedure a cone becomes exposed due to disengagement or during tissue advancement, the cone may be trimmed from the suture so that the suture end remains beneath the surface of the skin. Suture breakage is uncommon, but if it does occur, the suture need not be removed, as the material is entirely absorbable. While proper treatment planning and technique obviates the need to manage any asymmetry following the procedure, additional sutures may be added to ensure an optimal result. The results should be evaluated with the patient upright prior to trimming the suture ends. If a need for adjustment to the degree of tissue advancement emerges once a patient is upright, they may be reclined once again to adjust tissue advancement over the appropriate suture.

Post-Procedure Care 

Though placement of absorbable suspension sutures is a minimally invasive procedure, it does require diligent adherence to post-care instructions. Post-procedure recommendations presented here are somewhat less restrictive than in the authors’ 2017 consensus paper but must be followed to ensure optimal outcomes.Once the procedure is completed in the office, ice is applied for 30 minutes and Aquaphor® is applied to puncture sites. While patients may be instructed to continue icing for 24 hours, it should be noted that patients often apply too much pressure when icing at home and should either be instructed not to do so or instructions to ice at home may be omitted all together. Patients may wash their face or apply makeup after 24 hours, but these activities must be gentle, and pushing or pulling of the skin should be avoided. Early animal studies show that tissue integration of the suture’s knots is complete at one week, and the pull-out force of the suture plateaus at this time (Z.P. Lorenc, MD, personal communication). Therefore, great care should be taken not to disturb the suture with physical forces resulting from rigorous application of makeup, cleansing, chewing (a relatively soft diet is recommended), and distorting facial expressions such as grimacing for 1 week. During this week, patients should keep their head elevated on 2 pillows at night. Additional common activities that should be avoided include face-down massages, dental procedures or cleanings, and high impact exercise. Follow-up should include an office visit 3 to 5 days after treatment and again at 2 weeks if necessary. 

Nature and Duration of Outcomes

Though the physical lifting capacity of absorbable suspension sutures is responsible for immediate results and initial repositioning, the initial lift is complemented by a longer-lasting recontouring effect that is reflected by both patient- and investigator-reported