Introduction

History

The concept of barbed sutures was first patented by Al Camo in 1964, followed by Fukuda in 1984 and Ruff in 1994. These innovators conceptualized barbed sutures for wound closure without tying knots, but did not discuss aesthetic applications. Suture soft tissue elevation was pioneered in the late 1980s by Sulamanidze who in 1999 obtained worldwide patents for the subdermal (Aptos) thread product. In 2000, Sulamanidze popularized the concept of barbed sutures in facial cosmetic surgery and devised the name APTOS (Anti-PTOSis – meaning antiptosis) for his system of treating facial descent. The technique for suture lift was subsequently published by Sulamanidze et al. in December 2001, with a formal series presented in 2002. Current variation of this technique includes Contour Thread, also referred to as Thread Lift or Loop Lift (Surgical Specialties Corporation, Reading, PA) and the APTOS lift or Feather Lift (Kolster Methods, Inc., Corona, CA).

Both barbed suture design and treatment have evolved since their introduction. The original APTOS suture was a multiple-dented suture meant to provide additional traction in tissue. This design was modified to be bi-directional, with the barbs oriented so that tissue would be retained in the central region of the suture without the need for anchoring at either end (Fig. 28.1A). It was then re-designed as a multiple-barbed polypropylene suture intended to provide traction and suspension unidirectionally (Fig. 28.1B). Approval from the FDA for the extended length unidirectional barbed suture was obtained by two different companies in 2004 and 2005, respectively. No other variant of the barbed suture has received approval, but a newer technology called the Silhouette suture (Figs 28.1, Fig. 28.2), which involves the use of clear, flexible, absorbable cones with accompanying small knots on a polypropylene thread, to allow for more effective soft tissue elevation, received FDA approval in November 2006.

Fig. 28.1 Silhouette suture.

Fig. 28.2 Multiple-barbed polypropylene suture. Straight needle 8-inch, 20 G, curved needle non-cutting circle 26 mm.

At the meeting of the American Society of Aesthetic Plastic Surgery in New York City in April 2007, the Surgical Specialties Corporation announced the withdrawal of the Contour Thread from the market, stating that all production had ceased and that all remaining inventory could be returned to the company. As of this date, no other company is currently manufacturing the helical barbed suture typified by the Contour Thread. The company has now focused its efforts on the wound closure market with the introduction of its line of bi-directional barbed sutures intended for deep and superficial wound closure, either primary or secondary.

Physical evaluation

The new Silhouette suture is stronger than the conventional barbed sutures, it stands less chance of breakage, and it interacts with normal tissues through surrounding collagen tissue formation for better results. The suture consists of a 25 cm long 3-0 non-absorbable polypropylene suture that is 50% thinner than the 2-0 used in the design of the barbed sutures. This decreases knot palpability and pain in the temporal area. Suture strength is maintained by avoiding oblique cuts in the suture, in order to create the “barbs” (30–50% loss of suture strength). Each suture holds 11 clear, flexible, absorbable hollow cones that allow for tissue growth inside and around the cones (co-polymer of glycolic acid and lactic acid) (see Fig. 28.2). An immediate anchoring effect is created by the cones. A delayed anchoring effect is produced by a series of knots created on the distal 10 cm of the suture, which is intercolated with the cones (Fig. 28.3). The knots control the position of the cones and create further anchoring of the soft tissue, in turn creating collagen deposition around and inside each loop of the knot. These sutures can easily and safely be removed after the cones are completely absorbed using a small microphlebectomy hook.

Fig. 28.3 A delayed anchoring effect is produced by a series of knots created on the distal 10 cm of the suture, which is intercalated with cones.

The co-polymer cones (Fig. 28.4) are soft and avoid the pinprick effects of the barbed suture. Their large size (1.0 mm × 2.5 mm) creates a strong grasping effect on the fibrous soft tissue. The cones are hydrophilic, resulting in absorption of water and in a softer feel. They generate more collagen formation, due to the chemical interaction with the tissues, as well as the physical design of the device. A stronger soft tissue support is the result. The cones are absorbed over 8–10 months, with 50% of the device volume being absorbed in approximately five months (Fig. 28.5).

Fig. 28.4 Co-polymer cone.

Fig. 28.5 Advantages of the Silhouette suture versus conventional barbed sutures.

Current status of barbed sutures for cosmetic and wound closure applications

As explained above, the Surgical Specialties Corporation has withdrawn the Contour Thread from the market, and the company is now focusing its efforts on the wound closure market with the introduction of its line of bi-directional barbed sutures intended for deep and superficial wound closure.

A bi-directionally barbed suture has many barbs serially placed along its length, changing directions somewhere near the suture mid-point, in order to create a mirror image array of barbs in the opposite direction (Figs 28.6, 28.7). Therefore, when engaged in tissue, one end anchors the other end. This suture can be used to close wounds or move tissues differentially along the suture towards the point at which the barbs change direction. The company manufactures both non-absorbable and absorbable sutures, but only the latter (absorbable sutures) are approved for soft tissue approximation for wound closure. This particular suture is made of polydioxanone (PDO). The polymer hydrolyses and its strength degrades in an inverse fashion to the increase in strength of the healing wound.

Fig. 28.6 Barbed suture, self-anchoring, knot-less threads.

Fig. 28.7 Bidirectional barbed suture (A) and unidirectional barbed suture (B).

Both barbed and conventional sutures hold best when they engage connective tissue at a right angle to the collagen bundles; however, an ordinary closed loop generally compresses tissue at opposite poles, 180 degrees across from each other. A barbed suture holds better when each barb ensnares collagen fibers. The resulting sinuous passage is preferable to a straight one, as more collagen is encountered. A wavy path will straighten as the suture is tightened, but it will then encounter alternative vectors of force pushing against it. If a suture begins to pull out, new fibers are pressed against the barbs. In contrast, if the barbs in a suture traverse in a straight line, they will encounter a loosened column of tissue as it is pulled out. Undulations also impart elasticity, helping to prevent suture breakage, particularly with ballistic movements of the engaged tissue. Accordingly, curved needles naturally create a stronger closure than straight ones, and they can be used effectively in sinusoidal, helical and mattress patterns (Figs 28.8, 28.9).

Fig. 28.8 Closure of an abdominal wound showing barbed suture above and regular suture. below. Note the subcuticular weaving in the control suture.

Fig. 28.9 Subcuticular facelift closure initiated at the lobe.

Running closures begin near the middle of the wound. As the needle is pulled through the first bite of tissue, the barbs that immediately follow it compress against the shaft of the suture and impart little resistance. As soon as the opposing set of barbs meets the tissue, however, those barbs catch. Then subsequent bites are taken with the first needle until the end of the wound is closed, at which point the needle is simply cut off. The opposite end of the barbed suture closes the wound in a mirror image fashion.

Also notable is the dynamic behavior of a running closure using barbed sutures compared with conventional ones. Unlike a smooth closure, a barbed suture will not move to the portion of the wound where the tension is greatest (most frequently the center of the incision). Thus, a running barbed suture can provide security similar to a conventional interrupted one. Potentially, this may reduce the incidence of wound hernias and wide scars. It has been documented that the straight ends of barbed sutures are four times less prone to split than knotted ends when used in a running subcuticular fashion.

The first approved absorbable barbed sutures are made from PDO, which is often used for deep wound closures. Polydioxanone degrades commensurate with increases in wound strength in the soft tissues and the subperiosteal plane. Surgeons generally prefer more rapid degradation for intracuticular closures, in order to reduce the incidence of extrusion or spitting of the sutures. The Food and Drug Administration (FDA) approval is being sought for barbed versions of these polymers.

Marking and landmarks

Preoperative marking and preparation (Fig. 28.10): The white line represents the temporal crest, lateral orbital rim, and zygomatic arch. The green line divides the temporal area into its superomedial and inferolateral halves. The purple circles mark the medial zygomatic temporal vein (sentinel vein) and the lateral zygomatic temporal vein. The patient’s skin is marked preoperatively to determine appropriate suture orientation and to prevent injury to the temporal vessels and branches of the facial nerve. The mark for the temporal incisions, about 2 cm behind the hairline, is oriented roughly parallel to the hairline and measures about 3 to 4 cm. This places the incision in the medial half of the temporal area, about 1 cm lateral to the superior temporal crest.

Fig. 28.10 Landmarks, lower exit line.

The medial zygomatic temporal vein (or sentinel vein is approximately located at the lateral aspect of the lateral orbital rim. The lateral zygomatic temporal vein is at the superior border of the zygomatic arch, approximately 2 cm medial to the superior portion of the tragus of the ear.

The trajectory of the temporal branch of the facial nerve is marked by measuring from the lower portion of the tragus, to 1.5 cm cephalad, to the superior margin of the eyebrow. A safe passageway for the suture is marked between the medial and lateral zygomatic temporal vessels. This passageway is located under the temporoparietal fascia.

The distal areas of fixation or end points of the suture are marked. These are located at the inferior margin of the malar area. A line is drawn from the midpoint between the ala of the nose and the angle of the mouth to the inferior portion of the tragus. Six points are then marked over this line, starting 5 mm lateral to the nasolabial fold and proceeding at 1 cm intervals until all points are marked (Figs 28.11, 28.12).

Fig. 28.11 Landmarks, midface exit line.

Fig. 28.12 Technique variations. No dissection, closed melopexy.

Technical steps

Closed midface surgical procedure

The technique is performed under local anesthesia, with or without oral sedation, requiring about one hour for completion. Other complementary procedures can be performed at the same time (e.g. Botox, fillers for soft tissue augmentation, liposuction of the jowl, jaw line, and neck, etc.)

An incision is made in the temporal area approximately 2 to 3 cm behind the anterior hairline, and it is carried down to the deep temporal fascia (DTF) where a plane of blind soft tissue dissection is created between the superficial (STF) and deep temporal fascia (Figs 28.12, 28.13). This facilitates deployment of the 6-inch long straight Silhouette suture needle into the superficial fibrous adipose tissue of the lower temporal area, midface, and lower face. To enhance scar tissue adherence in the midface, insert the needles in pairs, passing the tip just through the exit point in the skin. Leave the needles in place, performing subcutaneous undermining with a small tissue dissector placed through the temporal incision on each side of the needles. Then pull the 6-inch needles completely out of the skin. This will leave intact bridges of tissue where each suture has been placed. The needle exit points are along a line drawn from the buccal commissure medially to the gonion of the mandible laterally. They begin just lateral to the nasolabial fold and are spaced 1 to 1.5 cm apart using a total of four to six sutures per side according to the patient’s needs.

Fig. 28.13 Technique variations. Temporal and malar dissection.

The curved taper needles on the proximal end of the suture are passed through the DTF and then tied in pairs. Tissue repositioning and suspension is accomplished first by tying the knots in the temporal area and then further tissue movement and remodeling are achieved by placing tension on the distal end of the suture and massaging the tissues overlying the sutures from medial to lateral. Distal suture ends can be cut off at the skin at the completion of the procedure or they can be left long to allow for further tissue shaping from one to three days after surgery. One-inch Steri-Strips (3M Healthcare, St. Paul, MN) or one-inch paper tape strips are used for five to seven days to support the facial tissues and minimize bruising and swelling.

Postoperative care

Fig. 28.14 Closed thread lift (62 years old), pre- and postoperatively.

Fig. 28.15 Endobrowlift and endofacelift, necklift, chin augmentation, upper and lower blepharoplasty and full face laser (49 years old), pre- and postoperatively.

Fig. 28.16 Endomidface with threads, necklift, fat transfer to NL, ML, lips, laser forehead, upper and lower eyelids, lateral canthal area (65 years old), pre- and postoperatively.

Complications

Pitfalls