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
measures of improvement and patient satisfaction. These positive changes have been shown within the context of a clinical study to endure for at least 12 months, but in the experience of the authors benefit endures for between 18 and 24 months.9,10 Because collagen stimulation by the PLLA/PLGA within the suture is not complete for between 4 and 6 months,13 it stands to reason that the mechanical and biostimulatory qualities of the suture act in concert to reposition and recontour facial tissue as well as improve skin quality. While “lift” in its purely technical sense may be considered the primary outcome of absorbable suspension suture treatment, the qualitative improvements in skin texture and contour are equally as important. This longer-term improvement is reflected by the authors’ experience with retreatment. In most cases, patients do not require retreatment for 24 months: generally, the revolumization that occurs as a result of PLLA/PLGA-induced collagenases obviates the need for additional suture placement before that time. In some cases, retreatment may include fewer sutures than the initial treatment. For example, the patient in Figure 3 was retreated at 16 months with a single suture.
Preventing and Treating Adverse Events
As with any medical procedure, a detailed knowledge of potential adverse events and how to best treat them is critical. Within the last 12 months, the adverse event rate per 106,810 devices sold is 0.006%.14 This remarkably low rate mirrors that observed for Silhouette Soft™ (Sinclair Pharma, London, UK), a physiochemically equivalent suture of similar design available in Europe.14 Swelling is relatively common, primarily as a result of the lidocaine injections, and dissipates within 2 to 3 days. Bruising is rare and may be managed by icing the area or treatment with lasers. While some practitioners may argue that patients should not take blood thinners for 1 week prior to suture placement, the potential risk of stopping blood-thinning therapy outweighs the increased likelihood of bruising. The patient should be counseled to avoid medically unnecessary supplements that may increase bruising, including vitamin E, garlic, ginger, and ginkgo. While hypersensitivity is rare, it does occur, and several case studies suggest that it can be successfully managed with steroids (Z.P. Lorenc, MD and M.S. Nestor, MD, PhD, personal communication). While minor bleeding consistent with a puncture is part of the treatment process, post-procedure bleeding or profuse bleeding during the procedure are rare and should be treated immediately. The patient should not experience pain during the procedure, and discomfort is a sign that the needle is outside of the correct plane.
Recommendations for Combination Treatments
While initial recommendations focused on treatment with absorbable suspension sutures as a single modality,5 the Silhouette InstaLift™ device is supportive of combination treatment with energy-based devices, neurotoxin, or fillers. These additional treatments not only enhance the impact of the procedure but are an important aspect of a complete treatment approach. Energy-based devices should ideally be used 6 weeks prior to suture placement so that the treatment does not disrupt the suture once it is placed. Neurotoxin is generally administered 1 week prior to suture placement and can be used to relax hyperkinetic muscles, alleviating the degree of force exerted on the cones, thereby maximizing their tissue repositioning potential. Volume replacement with fillers may be completed either 6 weeks prior to suture placement to permit integration and dissipation of swelling or administered on the day of the procedure. Generally, areas in which the suspension suture has been placed should not be treated with additional modalities on the day of the procedure, and only adjacent or distinct anatomical areas may be managed with filler or toxin. In some cases, however, lifting tissue can unmask volume deficits, and patients with moderate to severe volume deficits may be given fillers in those areas as long as fillers are placed outside of the subcutaneous plane. If administering fillers to an anatomical area where sutures have been placed, it is important to account for the eventual volume that results from the PLLA/PLGA within the sutures.
The applications of absorbable suspension sutures continue to expand, and research continues to emerge on more systematic inclusion of the jawline and jowls in initial patient assessments, as well as optimal application of absorbable suspension suture technology to the neck. Indeed, for some experienced practitioners, a practical approach to treatment may include 2 to 4 sutures in the midface, 1 to 2 sutures in the jowls or along the jawline, and 2 in the neck. Overall, the number of sutures needed for a holistic treatment approach that includes the midface, jowls, jawline, and neck is between 6 and 8 sutures per side. Utilization of this higher number of sutures reflects the interplay between each of these distinct segmental treatment areas. For example, the improvements gained by repositioning in the midface and jowls is further highlighted by improving jawline definition. While there have been some reports of sutures used for brow lifts, the results of the procedure are ambiguous, and patient satisfaction may be limited.
Absorbable suspension sutures fill an important gap in the treatment armamentarium: they provide a minimally invasive option for tissue repositioning that is expanding to include several distinct anatomical areas within the face and neck. Utilizing absorbable suspension sutures as a recontouring treatment in these areas, rather than as a basic lifting technique or surrogate for a surgical facelift, is critical for meeting patient expectations and ensuring high patient satisfaction. The recommendations presented here, including proper patient selection, vector determination, and suture placement can serve as a guide for physicians who hope to further develop their expertise and