History

Nature provides us with many barbed structures; such as the honeybee stinger, the woodpecker tongue and the porcupine quill; all can penetrate but defy being withdrawn. These barbs are all in one direction. In the early 1960s, Alcamo advanced the prehistoric inventions of a barbed fishing hook and arrowhead when he proposed a unidirectionally barbed suture.

In 1967 Alan McKenzie, M.D. reported on a bidirectionally barbed device he had created for tendon repair. None of these efforts were sustained.

In the early 1990s Ruff developed a bidirectional barbed device (Fig. 27.1), as well as its means of manufacture and method of use. Placed by a cannula or by needles deployed in opposite directions, one set of barbs anchors the other and eliminates the need to tie a knot to secure the end. The potential advantages over a knotted loop include less ischemic necrosis, greater surgeon control of tissue approximation, more speed and obviation of the manifold problems of the knot itself. The ability to realign tissues along the array of barbs may not only be used to compress the edges of a wound together, but also to reverse the ptosis associated with aging and weight loss. In the late 1990s, Drs. Harry Buncke and Marten Sulimanidze independently described similar concepts. The USFDA approved the use of barbed sutures for tissue suspension and approximation in 2003.

Fig. 27.1 Schematic depiction.

Currently barbed sutures are available in the US in permanent and absorbable polymers for tissue approximation.

Anatomy

Suspension of the skin constitutes the patient’s chief goal. As with open surgery, the placement of a barbed suture should elevate the subcutaneous fat as well. Likewise the barbs should be sufficiently deep in the fat to minimize distortion of the skin. The retinacula cutis of the face engages barbs surprisingly well, eliminating the need to enter the dermis. That being said, the barbs can lift the SMAS fascia in the cheek as well as SMAS muscles such as the platysma and the frontalis. Accordingly, knowledge of the thickness of the subcutaneous layer is important as is an appreciation of the gliding planes and cutaneous ligaments.

The force applied to the barbs in the face must be countered by an equally forceful opposite one. If the respective ends go in opposite directions, only half the barbs lift the face. In a U-shaped configuration, all the barbs engage the target and so this is more commonly used (Fig. 27.2).

Fig. 27.2 Methods of placement.

The forehead

The suture is anchored under the galea and extends toward the brow in the deep subcutaneous fat (Fig. 27.3). It is important to avoid placing the suture deep to the frontalis in the loose areolar plane because it will elevate the brows poorly and may “click” when the frontalis contracts. The vector of the lift is reviewed as the patient looks in the mirror.

Fig. 27.3 Brow lift options.

The supraorbital notch should be avoided, lest traction cause dysesthesias.

The midface

Excellent anchorage is provided by the deep temporal fascia. The barbs then extend more superficially in the SMAS and most distally in the malar fat pad. Placed more deeply, the sutures can retract the elevated malar periosteum and with it the origins of the zygomaticus and levator anguli oris muscles. If the periosteum is adequately released medially, this maneuver will elevate the oral commissure (Fig. 27.4). The barbs should not extend past the nasolabial fold where they will engage the orbicularis oris and so reduce traction on the malar fat pad. Rare instances of lower lid edema behoove the surgeon to stay inferior to the malar septum, though the reason for this occurrence is unknown. A practical guideline is to remain deep to the cheek, not eyelid skin.

Fig. 27.4 Subperosteal midface lift.

When reviewing the vector of lift with the patient, evaluate the lower lid for redundancy which may warrant resurfacing or even a pinch blepharoplasty.

Physical evaluation

Technical steps

The preceding sections on physical evaluation and anatomy have addressed the most pertinent reciprocities when selecting a vector and ancillary conditions that merit treatment.

With regard to the technique, it must be emphasized that more barbs are better for important reasons; each barb will be subjected to less force, hence less tissue creep or relapse, and broader distribution of the load lessens distortions of the skin.

For closed lifts, a permanent suture is preferred because the collagenous support of the face and neck remodel slowly when unwounded. For open procedures using an absorbable polydioxanone persists long enough for substantial wound strength to develop.