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.

The lower face

The more vertical the lift of the jowls, the tighter the neck. However, the caveats regarding excess lower lid skin which pertain to the midface also apply here. If a more horizontal vector is warranted, anchorage inferior to the deep temporal fascia is provided by the immobile SMAS and parotid capsule. As with the nasolabial fold, the barbs should not pass medial to the labiomental fold. They may extend over the mandibular border without distortion as long as the suture remains at the same depth below the skin as it courses into the neck.

The neck

Here the direction of pull should be parallel to or more horizontal than the mandibular border to prevent a redundant roll from forming at the mandibular angle (unless the lower face is lifted simultaneously). As with the arch of the brow, the suture ends straddle the cervicomental angle. The suture is anchored in the dense fascia inferior to the mastoid eminence and may be placed directly in an exposed platysma/SMAS or in the fat just superficial to this layer when the central neck remains closed. Unlike the bunching a conventional or purse-string suture creates, a barbed suture redistributes the tissues widely and incrementally, thereby minimizing the need to trim the excess. Care should be taken to stay superficial to the great auricular nerve.

Closed lifts

The polypropylene suture used herein has been withdrawn from the market and a replacement is being sought. The vector of lift is selected with the patient’s input. Usually local anesthesia will suffice with a benzalkonium prep. Two punctures 1.5 cm apart are made with an iris scissor after trimming the few adjacent hairs. The exit wound is dilated further with the scissor tips. The tip of the long straight needle is bent into of a circle with a chord of 1.5 cm, so it can easily pass from one puncture to the other.

A stout needle holder not only bends the needle, but provides reliable angular control of the curved needle. This initial passage of the needle provides the anchor and must therefore penetrate the relevant fascia. For the galea it skives just above the periosteum; more inferiorly when the tip engages the deep temporal fascia and the needle is pushed laterally, the skin remains stable relative to the deep structures. With a more superficial bite, and the skin moves over them. In the pre- and postauricular areas, a deep bite is taken and the security is assessed by lifting the tissue toward the surface. The needle then exits and is straightened while advancing the transition point of the barbs into the anchoring bite.

With one needle and its corresponding set of barbs emerging from each puncture, each needle is directed into its respective wound to a depth of 2 to 3 mm, then turned toward the distal target. The tip oscillates left and right in a plane parallel with the skin. Abrupt changes in its depth, however, will create depressions in the skin and are to be scrupulously avoided. This sinuous path provides more holding strength and a measure of elasticity to withstand ballistic movements of the face. Emerging from the skin just short of the target, the tip is again bent into a circle and clamped in the needle holder to control its rotation. The tip is withdrawn into the fat and thrust forward and out of the skin. This terminal curve adds strength and also deflects the suture’s end when the tissues are compressed, as when the patient smiles or raises the brow.

The ends of the suture are pulled distally to ‘seat’ the anchor while a single skin hook releases any tethering of the skin at the punctures and extracts any hair from them. Then the tissues are gently pushed proximally and the suture truncated by depressing the skin at the exit so that the end will lie several millimeters below the dermis.

For lower face and neck, the needles are straight and threaded by hand. For the midface and brow, they are arched to approximate the curvature of the face and then the needle holder applied to control rotation. As the needle oscillates in the forehead, the skin should move about half as much. If the needle is in the gliding plane deep to the frontalis, the skin will be minimally engaged. If the dermis is engaged the skin will more as much as the needle.

Open techniques

For patients with moderate laxity which creates significant brunching near the hairline, an open procedure might be best with just enough undermining to excise the redundancy, usually about 3 cm, just superficial to the SMAS (Fig. 27.5). The anchor is readily performed under direct vision and then the needles woven through the exposed SMAS, smoothly transitioning to the subcutaneous layer distally. Further mobility might be achieved by additionally undermining the galea and superficial temporal fascia.

Fig. 27.5 Locations of incisions.

The workhorse of these options is the temporal incision. From this area, of course, the midface can be addressed, but the pull is sufficiently vertical when directed at the jowls to suspend the neck as well (Figs 27.6–27.10).

Fig. 27.6 Temporal scalp incision.

Fig. 27.7 Needle modification: shape of long needle during procedure.

Fig. 27.8 Proximal fascial anchor.

Fig. 27.9 Tissue planes that sutures traverse.

Fig. 27.10 Plicating superficial fascia.

As an adjunct to conventional techniques, such as MACS lift or face with SMAS plication, the barbed suture can be woven through the platysma under direct vision, to augment or supplant the SMAS plication and purse-string sutures, and lift the brow with precise control of its shape (Figs 27.11–27.13). When pre- and postauricular skin have been elevated, a very secure anchor can be created by passing the first bite under the intact scalp (Fig. 27.14).

Fig. 27.11 MACS lift.

Fig. 27.12 MACS lift A, Dissected (0.0 mm). B, Purse string in SMAS lifts 8.5 mm). C, Absorbable barbed suture lift 10.0 mm. D, Both lift 13.0 mm.

Fig. 27.13 MACS lift, Barbed polydioxanone. A, Preoperative. B, 5 months postoperative.

Fig. 27.14 Combined lift. In a combined lift, the suture’s anchor lies above the ear in a reciprocal arrangement with its partner; the anchors are made in the superficial temporal fascia.

Barbed sutures with ordinary curved needles can be used to approximate tissues with conventional suture patterns. The closure typically begins at the middle of the wound with one needle advancing in each direction. The surgeon controls the tension of each bite, for the barbs will not allow it to back out or migrate to where the wound is under the greatest tension, as it does with a smooth suture in a continuous closure (Fig. 27.15). A running horizontal mattress for the galea, sinuous subcuticular for the deep dermis or over-and-over to plicate the malar fat provide speed and security for the closure and bite-by-bite control of suture tension.

Fig. 27.15 Deep dermal closure.

Fig. 27.16 Jowls and brows. Four threads, age: 49. A, Preoperative. B, 8 months postoperative.

Fig. 27.17 Jowls. Two threads; age: 61. A, Preoperative. B, 3 months postoperative.

Fig. 27.18 Jowls. Two threads; age: 61. A, Preoperative. B, 3 months postoperative.

Fig. 27.19 Cheek, jowls and neck. Six threads (Brow lifted with 2 threads and closed technique; age: 64. A, Preoperative. B, 12 months postoperative. C, 15 months postoperative (Neck redone at 12 months).

Fig. 27.20 Jowl. Two threads; age: 56. A, Preoperative. B, 8 months postoperative.