Sabrina G Fabi MDa, Robert Weiss MD FAADb, Susan H Weinkle MDc
aCosmetic Laser Dermatology, San Diego, CA bMaryland Dermatology Laser Skin & Vein Institute in Baltimore, MD (an affiliate of Anne Arundel Dermatology); Johns Hopkins University School of Medicine, Baltimore, MD; Department of Dermatology at the University of Maryland, Baltimore, MD cPrivate practice in Bradenton, Florida and an Affiliate Clinical Professor of Dermatology at the University of South Florida,Tampa, FL
Background: Absorbable suspension sutures are an effective nonsurgical modality for correction of ptosis and tissue repositioning in the face and neck. The PLLA/PLGA suture is entirely absorbable and has a dual effect in that it both lifts tissues and induces collagenesis, thereby restoring contour. In clinical practice, nonsurgical modalities are rarely used in isolation, and combination treatments with fillers, neuromodulators, lipolysis, and energy-based devices are common. Objectives: The aim of this study was to share the authors’ extensive experience in safely combing absorbable suspension sutures with other modalities in order to achieve optimal aesthetic outcomes for patients. The current work provides guidance to physicians who wish to incorporate absorbable suspension sutures into their aesthetics practice. Methods: The authors discuss patient selection and expectation setting, rationale for selection and ordering of treatments, and optimal treatment spacing. Technologies discussed include fillers, neuromodulators, microfocused ultrasound with visualization (MFU-V), radiofrequency, lasers and intense pulsed-light (IPL), microneedling, and lipolysis. Results: The authors share their approaches for combining nonsurgical techniques and present case studies illustrative of outcomes achievable through combination treatment with absorbable suspension sutures. The technical considerations for safely combining treatments such that optimal additive or synergistic benefit is reached for a particular patient are discussed. Conclusions: By combining nonsurgical modalities that address each of the four Rs (Repositioning tissue, Relaxation of hyperkinetic musculature, Resurfacing, and Revolumization),1 nonsurgical patient outcomes can be further improved. Absorbable suspension sutures represent a unique technology in that they are able to provide significant support to ptotic tissue in the face and neck.
Facial aging is the result of multiple interrelated processes. Reduced collagen and denaturation of the extracellular elastin fiber matrix leads to development of laxity and the atrophy characteristic of aging.2 In addition, volume loss in facial fat pads and bone resorption results in diminished facial volume, an issue compounded by attenuation of retaining ligaments and involution of bony attachments.3,4 Together, these processes lead to descent of facial features and inversion of the triangle of youth.5 Changes to skin texture and the development of static and dynamic lines are also apparent.The impact of the intrinsic factors detailed above is accompanied by the effects of extrinsic factors such photodamage due to UV exposure, damage due to smoking, or exposure to air pollution.4,6
In the arsenal of nonsurgical tools at the disposal of plastic surgeons and dermatologists is a wide array of devices designed to individually address elements of facial aging. Among these, absorbable suspension sutures are a unique technology for nonsurgical repositioning of facial tissue. Comprised of poly- L-lactic acid (PLLA) and poly-L-glycolide (PLGA) copolymers (82% PLLA monomers and 18% PGLA monomers), sutures are placed in the subcutaneous layer where they are able to support repositioned tissue and stimulate collagenesis. Along the length of the suture monofilament, bidirectional cones (4, 6, or 8 cones per side) serve to support repositioned tissue (Figure 1). On the inferior side of the suture, tissue is advanced and supported by the cones while cones on the superior side are used to anchor repositioned tissue in an elevated position.7
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