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
proximal exit point. While there are three suture sizes (8, 12, and 16 cones; See Table I), in the experience of the authors, the 8-cone suture is sufficient for most applications. 1% Lidocaine with epinephrine (1:100,000 dilution) is injected into the skin and subcutaneous layer at entry and exit sites using a 32-gauge needle (approximately 0.5 cc/ site). Local anesthetic is not required for needle pathways, which traverse the sub-cutaneous plane, and injection into these pathways may cause tissue distortion.The procedure should be painless: if the patient shows any sign that the procedure is painful, the sutures are in the incorrect plane. Importantly, the knots in the InstaLift suture must be tightened before placement: this may be done by applying steady tension to the ends of the suture. This step is critical to ensure the integrity of the device.Entry-site openings are made by placing an 18-gauge needle into the subcutaneous tissue in a perpendicular fashion past the deep aspect of the dermis, into the subcutaneous tissue.Sutures are then placed using the long, 23-gauge, 12cm needle that comes with the InstaLift sutures. This needle is placed into the single-entry point in a perpendicular fashion until it reaches the subcutaneous plane. The 5mm depth mark on the needle may be used as a guide. Once the needle reaches this point, it can be turned to a 90° angle to begin suture placement. The initial direction of the suture from the center point may be inferior or superior, depending on the preference of the surgeon. The needle is then advanced toward and through the previously marked exit site, pulling the cones with their closed sides first, which causes the free floating cones to cover the intercalated knots. Once the needle is completely through the exit site, it should be immediately amputated from the suture. The same procedure is then performed using the second needle to advance the other side of the suture from the entry site toward and through the second exit point. The authors recommend slightly depressing the tissue just to the side of the entry point where the cones are already in place in order to stabilize them as the other half of the suture is placed. To ensure that the cones have not caught on the dermis and that there is no puckering, each of the suture ends may be gently tensioned. A finger or thumb is then passed over the entry site to ensure that there is no excess suture remaining.Once the sutures are in place, it is important that the superior cones are engaged and remain aligned: a small amount of tension may be applied to the superior suture, and a thumb or finger gently run over the surface of the suture, without advancing the tissue. To advance the tissue over the inferior cones, place firm tension on the inferior suture and advance the tissue over the cones up to the entrance point. As the tissue is engaged (the patient and surgeon may
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