T he process of facial aging is a dynamic phenomenon involving changes of physical composition and physiologic function in the skin and underlying structures. The well-proportioned fat that characterizes a youthful face is eroded and displaced by time and gravity, producing certain key signs of an aging appearance: a clouded jaw line, an ill-defined chin-neck angle, cheek mounding at the smile lines, and/or malar puffs.1 Surgical management of the aging face has incorporated a wide range of new techniques and developments over the past few decades. Numerous methods to the facelift procedure are described, including the large-flap sculptured facelift, the extended supraplatysmal plane lift, midplane, deep-plane, biplane, triplane, superiosteal, endoscopic, vertical, transblepharoplasty, extended supraplatysmal, composite,etc., to name a few.2-8 Recently, minimally invasive rejuvenation techniques have proven to be very suitable options in dealing with specific facial subunits.9 In contrast to the traditional facelift surgical approach that addresses the entire face, limited rejuvenation procedures, such as the resuspension of the facial tissue ptosis and laxity, can be of great benefit to younger patients not seeking an aggressive approach. In this procedure a subdermal suspension thread is used to support the ptotic facial tissue without facelifting. PATIENT SELECTION As in any cosmetic procedure, patient selection is of paramount importance. Evaluate the underlying problem producing the aging effects of the face tissue laxity and discuss options frankly with the patient. It is of utmost importance that the patient fully understands the goals and has realistic expectations about the less noticeable improvements of this minimally invasive technique in comparison to the conventional facelift approach. Emphasize that the resuspension of ptotic facial tissue will only address specific facial subunits and that the patient may require additional cosmetic procedures as tissue relaxes with the passing of time. The thread-assisted lift is indicated in eyebrow lift and rejuvenation, forehead lift, cheek lift, augmentation or rejuvenation, nasolacrymal folds, nasolabial folds, midface sagging, jowls and the loss of mandibular rim definition, early platysmal correction, and neck rejuvenation.10 The ideal patient for this procedure is a younger person with early tissue sagging, mild rhytids and minimal redundant skin. Post-facelift patients whose surgical result currently requires mild to moderate improvement or touch-up are also candidates for this procedure. If a large degree of tissue involution and sagging is present, choose a more standard tuck or full rhytidectomy procedure. In the choice of the patient and appropriate procedure, a patient’s chronological age is less important than the general quality of the skin and supporting structures. As a rule, however, the younger the patient, the better the results. HISTORICAL BACKGROUND Facial rejuvenation techniques were revolutionized by the description of the superficial musculo-aponeurotic system by Mitz and Peironye in the 1970s. Since then, lifting techniques address this system. However, these techniques remain linked with the risk of complications associated with extensive cosmetic surgical procedures. Two decades later, Dr. M. Sulamanidze developed a means of supporting ptotic facial tissue by employing subdermal suspension threads. Between 1986 and 1989 Dr. Sulamanidze used these threads to lift facial tissue in 186 patients and proved that the technique was successful in lifting various ptotic areas of the face, improving facial contour for as long as 30 months of follow-up.10 In 1999, Dr. Sulamanidze obtained worldwide patents on his Aptos threads and currently, the “Aptos” name has been trademarked in the United States.11 Recently, Lycka, et al., published a large case study where Aptos technique was performed in 350 female patients, strongly suggesting that Aptos subdermal suspension thread technique provides an effective and much safer alternative to current facelift procedures for facial rejuvenation in the appropriately selected patient.11 TECHNIQUE We use the Aptos product, threads made out of polypropylene, which are available in 2-0, 3-0 and various lengths. The size and length of the threads are chosen depending mostly on the area to be lifted and the degree of facial tissue ptosis. (See photo 1.) We routinely employ intravenous conscious sedation for most of our patients undergoing cosmetic surgical procedures, utilizing a certified ambulatory surgical suite. This procedure, however, can be easily and safely performed in an office setting. Mark the patient in an upright position to ensure symmetrical as well as optimal thread placement. Maintain gentle pressure to assess the response of the patient’s facial tissue and desired lifting. (See photo 2.) Following the marks drawn on the patient’s skin, insert the threads into the subcutaneous layer of the skin with an 18-gauge spinal needle. Place special attention in positioning the threads as superficial as possible without making them visible. The threads should be placed in such a way to reverse the direction of the aging vector. For brow lift, the pulling should be directed mostly superiorly. However, the aging vector for the mid and lower face is not only downward but also inward, so suspend the tissue in the superolateral direction. Moreover, depending on the area to be lifted, the threads need to be placed in different subcutaneous levels. For eyebrow correction, the sutures run subdermally or even intradermally, while lifting the buccozygomatic areas requires a deeper plane in the subcutaneous fat to be able to curve around and create the contour of the cheek. After inserting the cannula, remove the trochar from the spinal needle and retract the threads to delineate the appropriate suture placement. (See photos 3 and 4.) Use multiple threads and various lengths in order to attain the desired correction of the facial tissue laxity. At the completion of the procedure, return the patient to the sitting position and assess the symmetry of the lifting. Apply ice to the areas, and instruct patients to avoid heavy exertion and vigorous facial movements for 3 days. DISCUSSION The dynamic process of aging results in a varied spectrum of tissue changes. Modern facelift surgery addresses changes in the skin, fat, subcutaneous tissue, SMAS and muscle, utilizing standard and innovative approaches. It is well understood that not all patients display the same degree of change in these tissues. Patients with early tissue sagging and laxity may benefit from this limited approach that addresses a particular facial area of major concern to the patient. Patients with moderate to extensive skin laxity are not candidates for this procedure and require a conventional rhytidectomy procedure. Aptos threads are made with slits, thus creating slant edges with sharp ends. These slits provide one-way travel of the thread in the soft tissue. After the thread is inserted under the skin, the slits prevent the thread from moving in the opposite direction, thus providing stable fixation of the facial tissue. In our experience, patients with minimal sagging of the facial skin are the best candidates. (See photos 5A, 5B and 5C.) We personally have found the Aptos technique especially helpful for brow lifts, where skin tonicity is well maintained. (See photos 6A and 6B.) In addition, over the lower face, the subtle blunting of the mandibular angle is an area that also responds very well to this technique. However, if there are large areas of skin redundancy and prominent fat deposition, the tuck procedures are required. Similarly, rejuvenation of the submental area is best addressed by a liposuction procedure, where the fat pad is reduced and skin redundancy contracts. In our experience, complications have been minimal, with only variable bruising, mild swelling, and occasionally a slight dimpling of the skin at the suture’s placement sites. These are transient, requiring no additional correction. Patients with concerns of aging in a particular facial subunit may not be candidates for the classic facelifting techniques, which address the whole face rather than a particular facial subunit. Invasive and extensive rhytidectomy techniques are being gradually replaced with minimally invasive rejuvenation procedures focused on specific facial areas with the least post-operative discomfort, short recovery time and minimal post-operative complications. We have added the subdermal suspension threads, Aptos, to our armamentarium of minimally invasive techniques for facial rejuvenation. Used alone or with other minimally invasive rhytidectomy techniques, Aptos has proven to be a simple, minimally invasive and safe procedure that requires no patient down time.
Exploring Aesthetic Interventions, Part VIII: A Minimally Invasive Thread-Assisted Lift
T he process of facial aging is a dynamic phenomenon involving changes of physical composition and physiologic function in the skin and underlying structures. The well-proportioned fat that characterizes a youthful face is eroded and displaced by time and gravity, producing certain key signs of an aging appearance: a clouded jaw line, an ill-defined chin-neck angle, cheek mounding at the smile lines, and/or malar puffs.1 Surgical management of the aging face has incorporated a wide range of new techniques and developments over the past few decades. Numerous methods to the facelift procedure are described, including the large-flap sculptured facelift, the extended supraplatysmal plane lift, midplane, deep-plane, biplane, triplane, superiosteal, endoscopic, vertical, transblepharoplasty, extended supraplatysmal, composite,etc., to name a few.2-8 Recently, minimally invasive rejuvenation techniques have proven to be very suitable options in dealing with specific facial subunits.9 In contrast to the traditional facelift surgical approach that addresses the entire face, limited rejuvenation procedures, such as the resuspension of the facial tissue ptosis and laxity, can be of great benefit to younger patients not seeking an aggressive approach. In this procedure a subdermal suspension thread is used to support the ptotic facial tissue without facelifting. PATIENT SELECTION As in any cosmetic procedure, patient selection is of paramount importance. Evaluate the underlying problem producing the aging effects of the face tissue laxity and discuss options frankly with the patient. It is of utmost importance that the patient fully understands the goals and has realistic expectations about the less noticeable improvements of this minimally invasive technique in comparison to the conventional facelift approach. Emphasize that the resuspension of ptotic facial tissue will only address specific facial subunits and that the patient may require additional cosmetic procedures as tissue relaxes with the passing of time. The thread-assisted lift is indicated in eyebrow lift and rejuvenation, forehead lift, cheek lift, augmentation or rejuvenation, nasolacrymal folds, nasolabial folds, midface sagging, jowls and the loss of mandibular rim definition, early platysmal correction, and neck rejuvenation.10 The ideal patient for this procedure is a younger person with early tissue sagging, mild rhytids and minimal redundant skin. Post-facelift patients whose surgical result currently requires mild to moderate improvement or touch-up are also candidates for this procedure. If a large degree of tissue involution and sagging is present, choose a more standard tuck or full rhytidectomy procedure. In the choice of the patient and appropriate procedure, a patient’s chronological age is less important than the general quality of the skin and supporting structures. As a rule, however, the younger the patient, the better the results. HISTORICAL BACKGROUND Facial rejuvenation techniques were revolutionized by the description of the superficial musculo-aponeurotic system by Mitz and Peironye in the 1970s. Since then, lifting techniques address this system. However, these techniques remain linked with the risk of complications associated with extensive cosmetic surgical procedures. Two decades later, Dr. M. Sulamanidze developed a means of supporting ptotic facial tissue by employing subdermal suspension threads. Between 1986 and 1989 Dr. Sulamanidze used these threads to lift facial tissue in 186 patients and proved that the technique was successful in lifting various ptotic areas of the face, improving facial contour for as long as 30 months of follow-up.10 In 1999, Dr. Sulamanidze obtained worldwide patents on his Aptos threads and currently, the “Aptos” name has been trademarked in the United States.11 Recently, Lycka, et al., published a large case study where Aptos technique was performed in 350 female patients, strongly suggesting that Aptos subdermal suspension thread technique provides an effective and much safer alternative to current facelift procedures for facial rejuvenation in the appropriately selected patient.11 TECHNIQUE We use the Aptos product, threads made out of polypropylene, which are available in 2-0, 3-0 and various lengths. The size and length of the threads are chosen depending mostly on the area to be lifted and the degree of facial tissue ptosis. (See photo 1.) We routinely employ intravenous conscious sedation for most of our patients undergoing cosmetic surgical procedures, utilizing a certified ambulatory surgical suite. This procedure, however, can be easily and safely performed in an office setting. Mark the patient in an upright position to ensure symmetrical as well as optimal thread placement. Maintain gentle pressure to assess the response of the patient’s facial tissue and desired lifting. (See photo 2.) Following the marks drawn on the patient’s skin, insert the threads into the subcutaneous layer of the skin with an 18-gauge spinal needle. Place special attention in positioning the threads as superficial as possible without making them visible. The threads should be placed in such a way to reverse the direction of the aging vector. For brow lift, the pulling should be directed mostly superiorly. However, the aging vector for the mid and lower face is not only downward but also inward, so suspend the tissue in the superolateral direction. Moreover, depending on the area to be lifted, the threads need to be placed in different subcutaneous levels. For eyebrow correction, the sutures run subdermally or even intradermally, while lifting the buccozygomatic areas requires a deeper plane in the subcutaneous fat to be able to curve around and create the contour of the cheek. After inserting the cannula, remove the trochar from the spinal needle and retract the threads to delineate the appropriate suture placement. (See photos 3 and 4.) Use multiple threads and various lengths in order to attain the desired correction of the facial tissue laxity. At the completion of the procedure, return the patient to the sitting position and assess the symmetry of the lifting. Apply ice to the areas, and instruct patients to avoid heavy exertion and vigorous facial movements for 3 days. DISCUSSION The dynamic process of aging results in a varied spectrum of tissue changes. Modern facelift surgery addresses changes in the skin, fat, subcutaneous tissue, SMAS and muscle, utilizing standard and innovative approaches. It is well understood that not all patients display the same degree of change in these tissues. Patients with early tissue sagging and laxity may benefit from this limited approach that addresses a particular facial area of major concern to the patient. Patients with moderate to extensive skin laxity are not candidates for this procedure and require a conventional rhytidectomy procedure. Aptos threads are made with slits, thus creating slant edges with sharp ends. These slits provide one-way travel of the thread in the soft tissue. After the thread is inserted under the skin, the slits prevent the thread from moving in the opposite direction, thus providing stable fixation of the facial tissue. In our experience, patients with minimal sagging of the facial skin are the best candidates. (See photos 5A, 5B and 5C.) We personally have found the Aptos technique especially helpful for brow lifts, where skin tonicity is well maintained. (See photos 6A and 6B.) In addition, over the lower face, the subtle blunting of the mandibular angle is an area that also responds very well to this technique. However, if there are large areas of skin redundancy and prominent fat deposition, the tuck procedures are required. Similarly, rejuvenation of the submental area is best addressed by a liposuction procedure, where the fat pad is reduced and skin redundancy contracts. In our experience, complications have been minimal, with only variable bruising, mild swelling, and occasionally a slight dimpling of the skin at the suture’s placement sites. These are transient, requiring no additional correction. Patients with concerns of aging in a particular facial subunit may not be candidates for the classic facelifting techniques, which address the whole face rather than a particular facial subunit. Invasive and extensive rhytidectomy techniques are being gradually replaced with minimally invasive rejuvenation procedures focused on specific facial areas with the least post-operative discomfort, short recovery time and minimal post-operative complications. We have added the subdermal suspension threads, Aptos, to our armamentarium of minimally invasive techniques for facial rejuvenation. Used alone or with other minimally invasive rhytidectomy techniques, Aptos has proven to be a simple, minimally invasive and safe procedure that requires no patient down time.
T he process of facial aging is a dynamic phenomenon involving changes of physical composition and physiologic function in the skin and underlying structures. The well-proportioned fat that characterizes a youthful face is eroded and displaced by time and gravity, producing certain key signs of an aging appearance: a clouded jaw line, an ill-defined chin-neck angle, cheek mounding at the smile lines, and/or malar puffs.1 Surgical management of the aging face has incorporated a wide range of new techniques and developments over the past few decades. Numerous methods to the facelift procedure are described, including the large-flap sculptured facelift, the extended supraplatysmal plane lift, midplane, deep-plane, biplane, triplane, superiosteal, endoscopic, vertical, transblepharoplasty, extended supraplatysmal, composite,etc., to name a few.2-8 Recently, minimally invasive rejuvenation techniques have proven to be very suitable options in dealing with specific facial subunits.9 In contrast to the traditional facelift surgical approach that addresses the entire face, limited rejuvenation procedures, such as the resuspension of the facial tissue ptosis and laxity, can be of great benefit to younger patients not seeking an aggressive approach. In this procedure a subdermal suspension thread is used to support the ptotic facial tissue without facelifting. PATIENT SELECTION As in any cosmetic procedure, patient selection is of paramount importance. Evaluate the underlying problem producing the aging effects of the face tissue laxity and discuss options frankly with the patient. It is of utmost importance that the patient fully understands the goals and has realistic expectations about the less noticeable improvements of this minimally invasive technique in comparison to the conventional facelift approach. Emphasize that the resuspension of ptotic facial tissue will only address specific facial subunits and that the patient may require additional cosmetic procedures as tissue relaxes with the passing of time. The thread-assisted lift is indicated in eyebrow lift and rejuvenation, forehead lift, cheek lift, augmentation or rejuvenation, nasolacrymal folds, nasolabial folds, midface sagging, jowls and the loss of mandibular rim definition, early platysmal correction, and neck rejuvenation.10 The ideal patient for this procedure is a younger person with early tissue sagging, mild rhytids and minimal redundant skin. Post-facelift patients whose surgical result currently requires mild to moderate improvement or touch-up are also candidates for this procedure. If a large degree of tissue involution and sagging is present, choose a more standard tuck or full rhytidectomy procedure. In the choice of the patient and appropriate procedure, a patient’s chronological age is less important than the general quality of the skin and supporting structures. As a rule, however, the younger the patient, the better the results. HISTORICAL BACKGROUND Facial rejuvenation techniques were revolutionized by the description of the superficial musculo-aponeurotic system by Mitz and Peironye in the 1970s. Since then, lifting techniques address this system. However, these techniques remain linked with the risk of complications associated with extensive cosmetic surgical procedures. Two decades later, Dr. M. Sulamanidze developed a means of supporting ptotic facial tissue by employing subdermal suspension threads. Between 1986 and 1989 Dr. Sulamanidze used these threads to lift facial tissue in 186 patients and proved that the technique was successful in lifting various ptotic areas of the face, improving facial contour for as long as 30 months of follow-up.10 In 1999, Dr. Sulamanidze obtained worldwide patents on his Aptos threads and currently, the “Aptos” name has been trademarked in the United States.11 Recently, Lycka, et al., published a large case study where Aptos technique was performed in 350 female patients, strongly suggesting that Aptos subdermal suspension thread technique provides an effective and much safer alternative to current facelift procedures for facial rejuvenation in the appropriately selected patient.11 TECHNIQUE We use the Aptos product, threads made out of polypropylene, which are available in 2-0, 3-0 and various lengths. The size and length of the threads are chosen depending mostly on the area to be lifted and the degree of facial tissue ptosis. (See photo 1.) We routinely employ intravenous conscious sedation for most of our patients undergoing cosmetic surgical procedures, utilizing a certified ambulatory surgical suite. This procedure, however, can be easily and safely performed in an office setting. Mark the patient in an upright position to ensure symmetrical as well as optimal thread placement. Maintain gentle pressure to assess the response of the patient’s facial tissue and desired lifting. (See photo 2.) Following the marks drawn on the patient’s skin, insert the threads into the subcutaneous layer of the skin with an 18-gauge spinal needle. Place special attention in positioning the threads as superficial as possible without making them visible. The threads should be placed in such a way to reverse the direction of the aging vector. For brow lift, the pulling should be directed mostly superiorly. However, the aging vector for the mid and lower face is not only downward but also inward, so suspend the tissue in the superolateral direction. Moreover, depending on the area to be lifted, the threads need to be placed in different subcutaneous levels. For eyebrow correction, the sutures run subdermally or even intradermally, while lifting the buccozygomatic areas requires a deeper plane in the subcutaneous fat to be able to curve around and create the contour of the cheek. After inserting the cannula, remove the trochar from the spinal needle and retract the threads to delineate the appropriate suture placement. (See photos 3 and 4.) Use multiple threads and various lengths in order to attain the desired correction of the facial tissue laxity. At the completion of the procedure, return the patient to the sitting position and assess the symmetry of the lifting. Apply ice to the areas, and instruct patients to avoid heavy exertion and vigorous facial movements for 3 days. DISCUSSION The dynamic process of aging results in a varied spectrum of tissue changes. Modern facelift surgery addresses changes in the skin, fat, subcutaneous tissue, SMAS and muscle, utilizing standard and innovative approaches. It is well understood that not all patients display the same degree of change in these tissues. Patients with early tissue sagging and laxity may benefit from this limited approach that addresses a particular facial area of major concern to the patient. Patients with moderate to extensive skin laxity are not candidates for this procedure and require a conventional rhytidectomy procedure. Aptos threads are made with slits, thus creating slant edges with sharp ends. These slits provide one-way travel of the thread in the soft tissue. After the thread is inserted under the skin, the slits prevent the thread from moving in the opposite direction, thus providing stable fixation of the facial tissue. In our experience, patients with minimal sagging of the facial skin are the best candidates. (See photos 5A, 5B and 5C.) We personally have found the Aptos technique especially helpful for brow lifts, where skin tonicity is well maintained. (See photos 6A and 6B.) In addition, over the lower face, the subtle blunting of the mandibular angle is an area that also responds very well to this technique. However, if there are large areas of skin redundancy and prominent fat deposition, the tuck procedures are required. Similarly, rejuvenation of the submental area is best addressed by a liposuction procedure, where the fat pad is reduced and skin redundancy contracts. In our experience, complications have been minimal, with only variable bruising, mild swelling, and occasionally a slight dimpling of the skin at the suture’s placement sites. These are transient, requiring no additional correction. Patients with concerns of aging in a particular facial subunit may not be candidates for the classic facelifting techniques, which address the whole face rather than a particular facial subunit. Invasive and extensive rhytidectomy techniques are being gradually replaced with minimally invasive rejuvenation procedures focused on specific facial areas with the least post-operative discomfort, short recovery time and minimal post-operative complications. We have added the subdermal suspension threads, Aptos, to our armamentarium of minimally invasive techniques for facial rejuvenation. Used alone or with other minimally invasive rhytidectomy techniques, Aptos has proven to be a simple, minimally invasive and safe procedure that requires no patient down time.
