Suspension for the Aging Face
Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Rejuvenation of the aging face involves modalities that will:

• Refill
• Resurface
• Relax and
• Resuspend

As cosmetic rejuvenation procedures have become simpler and less-aggressive, the down-time has decreased as well as safety and morbidity. Most facial rejuvenation involves a combination of these procedures which can then be tailored to the needs of the patient. (Table I)

The aging face exhibits both intrinsic effects of volume loss and ptosis plus photoaging changes on the skin. Volume and ptosis first exhibits changes in the nasolabial fold which has a dynamic phase and then later a static phase.(Fig 1) It is interesting that the fold is absent in the newborn and disappears in the paralyzed face, revealing the importance of the dynamic phase. It is the result of both perioral and lower face volume loss with cheek skin ptosis. The volume loss involves atrophy of the lower facial fat muscle and bone in the perioral and cheek areas.(Fig 2) The nasolabial fold represents the peripheral margin of the orbicularis oris muscle at the infusion of the cheek levator muscles. It is, though, the overlying subcutaneous fat – the malar fat pad – that normally gives the youthful cheek a rounded convexity that merges smoothly with the nasolabial fold. The SMAS has the muscle-fat complex in place, giving it final definition and stability during movement of facial muscles. The fold deepens with age because of atrophy and ptosis of the malar fat pad, cheek-skin laxity and hypertonicity of the levator muscle on the lip margin.(Fig 3) Later, ptosis and atrophy of the malar fat pad characterizes the static phase of the deepening nasolabial fold.1 (Fig 4) Procedures for rejuvenation of the mid face include:

1) Soft tissue augmentation
2) Mid face lifting procedures
3) Direct melolabial fold excision
4) Adjunctive procedures
a. CO2 laser
b. Botulinum toxin
c. Non-ablative laser and tissue tightening lasers

Skin fillers are only useful for early or mid to moderate nasolabial fold depressions. These include collagen products (Cosmoplast, Zyplast) and varying concentrations of hyaluronic acid fillers such as Hylaform, Restylane and Captique.(Fig 5) Longer lasting skin fillers must be injected deeper such as hydroxyapetite (Radiesse) and Silikon.2

For more severe volume loss problems, microlipoinjection of fat into subcutaneous tissue and muscle – FAMI – has been the treatment of choice. It will lost replace volume and accordingly produce some elevation as it pushes the cheek and malar fat pad back up. (Fig 6) Polylactic acid suspensions – Sculptra – produces volume filling by stimulating new collagen production in the subcutaneous tissue and deeper dermis. It also uses volume filling as well as some elevation of ptotic mid face structures.3 (Fig 7)

Though soft tissue implants can correct early problems of the aging face with volume loss and ptosis, more advanced facial aging conditions are problematic. This is because the implants are absorbable and temporary. They also do not address the ptotic malar fat pad and the nasolabial cheek bulge and do not change cheek contour. These conditions can only be addressed with lifting procedures. Procedures currently used include:

1) Traditional rhytidectomy with SMAS lift
2) Subperiosteal mid face lifts
3) Deep plane lifts 4

During the last decade, the trend in lifting technique has become less invasive surgical techniques include endoscopic malar fat pad elevation and malar fat pad fixation with liposculpture.5 Minimally invasive lifting techniques have evolved such as percutaneous cable suture elevation as performed by Sasaki with vortex grafts anchored to temporal fascia.6

Both here in the United States and abroad, the most recent minimally-invasive lifting technique has been the barbed threads used for suspension. The Aptos subdermal suspension threads evolved from the concept of skin and fascia adhering to the barbed suture, creating elevation. This was developed by Marlen and George Sulamanidze in Russia.7 Concomitantly, the Contour Thread developed by Dr. Greg Ruff at Duke University and in the United States is now FDA approved and used as a similar barbed suspension thread.8 The suspension threads simplify the procedure of lifting by eliminating surgical incisions, undermining, plication SMAS, and suturing the various tissues back together. This simplified procedure reduces operative time, anesthesia, post-operative recovery and reduces the risk of face lift complications including hematoma, flap necrosis, infection, nerve damage and scarring. The barbed suture can be performed with local anesthesia through needle insertion in the subcutaneous tissue utilizing soft tissue vectors of upward suspension. Two devices have evolved simultaneously. The barbed Contour Thread by Greg Ruff, M.D. evolved in concept over the early 90’s and has recently become FDA approved in the U.S. for cheek, jowl and brow-lifting. The Aptos thread was developed by Marlen Sulamanidze in the 90’s. At present, it is not an approved device in the U.S.

Aptos is derived from the Greek “Anti” plus “Ptosis”. It is essentially a barbed thread which adheres to the dermis and acts as a gathering stitch or Velcro. The aptos thread is based on the concept that the skin can be lifted and held in a suspended position with barbs alone without affecting the underlying muscle or bone. The barbed adherence is performed without suturing or anchoring to fascia muscle or bone.

The thread itself is polypropylene, a nylon suture with barbed incisions in two directions. The bidirectional barbs thus hold tissue in both inferior and superior direction, giving greater adherence.(Fig 9) The aptos suture is introduced in an 18 or 20 gauge spinal needle in the subcutaneous tissue from the superior point of suspension to the lower limits of ptotic skin. For the nasolabial fold, the pathways traverse from the lateral malar cheek to the nasolabial fold and the lateral oral commissure.(Fig 10) As the spinal needle is removed and the cheek compressed upward, the barbs open up with pull on the suture. The barbs then grab skin and associated subcutaneous tissue, holding it in the new elevated position. The protruding suture is then cut at the skin surface and tucked into the subcutaneous tissue. The procedure is performed in the following stage:

1) A map of vectors is drawn on the patient’s face in a seated position to determine the pathways of the threads and the number of threads needed to obtain the necessary elevation.(Fig 11)
2) The patient’s face is cleansed and sterilized with an appropriate surgical scrub so that the procedure can be performed sterily.
3) The procedure can be performed with local anesthesia alone; though I prefer using minimal anxiolytic sedation (diazepam 5-10 mg sublingually to supplement the local anesthesia alone). 1% lidocaine with 1:150,000 epinephrine with bicarbonate is used to infiltrate the skin and subcutaneous pathway. One can use a 1 ½ inch 30 gauge needle and 10 cc syringe producing first a bleb intradermally at the point of insertion, then a subcutaneous infiltration of the suture pathway. This usually produces enough anesthesia for painless placement of the suspension suture.
4) A 20 gauge spinal needle – trochar in place – is introduced through the skin and advanced along the mapped pathway with a “serpiginous” pattern. This is to increase the tissue area of barbed contact and the changing of direction creates a stronger barbed attachment. The needle is advanced to its termination at the nasolabial fold and exited to the skin. The trochar is removed and the barbed suture introduced into the spinal needle from the termination point to the beginning. The inferior portion of protruding thread is clamped with a hemostat for security as the spinal needle is removed. At the same time, the cheek is compressed upward. After the needle is removed superiorly, the thread is pulled in both directions, opening the barb and holding the skin in its upward compressed position. The two sides are then compared for symmetry and even correction. At this time, change can be made to equal the elevation and create a natural lifting. The protruding sutures are then snipped with suture scissors and the suture tucked in to the subcutaneous tissue.(Fig 12, 13, 14, 15,)
5) Antibiotic ointment is placed over the needle holes and steri-strips or micropore tape is placed over the cheeks for surface anti-tension suspension. (Fig 16)

Post-operatively, the patient is warned against excessive cheek or moderate mouth movement which – early on – can break the correction. Also, the patient is advised against massage or aggressively scraping the cheeks for the first few days which can also dislodge the barbs. My preference is to leave the tapes in place for the first five days; then advise the patient to re-tape at night, protecting the cheeks from sleep compression and immobilizing the tissues. In a majority of patients, the correction has been maintained for two to three years if early immobilization can be maintained. This has been reported by Sulamanidze and Lycka in two independent series.3,9

Basic questions have arisen as to the reason the barbs will maintain correction without anchorage to a mobile structure such as muscle or bone. Sulamanidze performed histopathologic studies on albino rats with inserted barbed threads in a control of non-notch prolene suture. The tissues were examined with special stains for collagen, fibroblasts and vascular response. A surprising difference was noted between the barbed suture and its control. The smooth prolene suture had no vascular, inflammatory, fibroblastic or collagen response with serial biopsies taken regularly up to six months. The barbed suture, though, demonstrated an early inflammatory response followed by a vascular proliferation and fibroblastic reaction, creating a collagen cuff around the barbs.11 (Fig 17) This, then, must account for the grip the barbs continue to hold on skin, giving it its longer-lasting response. It also explains the need to immobilize the skin in tissues early on until the collagen response is complete.

Further studies were performed by Lee WS et al to compare the tensile strength, skin compressibility and histology of barbed suture versus prolene suture. There studies demonstrated uniformly that the barbed sutures maintain greater tensile strength measured in pounds per square inch and greater skin compression than the plain suture. Histology in the rat model demonstrated myofibroblasts with a fibrotic cuff around the barbed suture and no fibroblastic response seen in the plain suture material, either monofilamentus or multifilamentus.12

This all adds scientific principle to the clinical results seen with the barbs. They are different in their results from plain suture material. The true test of the procedure, though, is in patient satisfaction.

Lycka et.al. followed 350 patients who had aptos threads placed for nasolabial fold, cheek and brow lifting. They found over 75% of the patients reported a favorable response with few side effects. The majority of them reported results lasting over one year. Fifty-two patients did, though, require a post-operative touch-up because of early destruction of results.13

Side-effects and complications seen include the following:

1) Asymmetry
2) Visible threads
3) Suture spitting
4) Post-operative pain
5) Infection
6) Correction destroyed by manipulation 14

Symmetry problems can be addressed at the conclusion of surgery and during early post-operative visits. Finger massage and manipulation can correct an overly-corrected cheek or side within the first week. It is, thus, important to see the patient during the first week to evaluate the results.

Threads may be visible early on, especially in the patient who has thin skin and little subcutaneous tissue. This usually improves with time. If it persists to the patient’s dissatisfaction after three or four weeks, the barbed suture can be removed.

Suture migration or spitting at the surface has been seen. The protruding suture can be easily snipped or a wandering suture removed.(Fig 18)

Infection is rare, especially with pre-operative antibiotics. Precautions of asepsis and sterility should prevent this.

The patient may complain of a pinching pain early on which is intermittent. I believe it is caused by the barb irritating a peripheral nerve. This usually occurs within the first week and subsides. The patient needs reassurance and this is usually all that is necessary; though, if it persists and creates a symptomatic problem, the suture may be removed.

The most important adverse sequelae is the destruction of correction by stretching the barb early on. Correct technique of insertion – using a serpentine pattern – along with proper post-operative protection can guard against this problem. Other areas of ptosis and dermatocholasis treated with aptos suspension threads include eyebrow and forehead lifting, cheek lifting, jowls and neck with platysmal suspension. The technique and procedure is essentially the same for each of these procedures; only the patterns and number of threads change as to the structure to be lifted. Forehead and brow give excellent results and can be combined with upper lid blepharoplasty. Cheeks and jowls can be more problematic with correction broken with cheek movement.

This is a technique in development with questions remaining as to longevity and the best areas for treatment.(Fig 19)

Contour Threads
Greg Ruff, M.D. has independently developed a different concept of barbed suture for facial suspension. Having used the model of the porcupine quill (erethizon dursaton) as a multi-barbed suture that maintains a hold or grasp on soft tissue through an even and spiral diffusion of barbs on each quill. Dr. Ruff began work on the “quill suture” in the early 90’s as a closure technique for surgical wounds. It was found to be self-anchoring with no knots, giving a faster and more efficient closure with tension broadly distributed. The “Contour Suture” was thus developed as a unidirectional barbed monofilament suture with a different pattern of insertion and anchored superiorly to a fixed structure. Data has been obtained as to tensile strength, tissue stretch and histologic studies of fibroblast migration and collagen development and this has shown to be a safe and reliable technique for facial suspension.16 In 2005, the FDA has approved it for suture suspension for cheeks, jowls and brow.(Fig 20)

The 25 cm. 2-0 prolene barbed suture is swedged onto a 7 inch straight needle with a tapered cutting tip and 26 mm. ½ circle tapered needle on the opposite end for suture fixation.(Fig 21) The sutures are used in pairs with the pathways ascending superiorly to a pointed V in the temporal scalp. At this superior point, the fixation needle is used to anchor the suture in the temporal fascia. The procedure is performed sterily as the aptos threads are employed with an initial incision made superiorly and the straight needle threaded through the subcutaneous tissue in a serpentine pattern.(Fig 22) Each pair of threads are tied in the superior temporal fascia. As the threads are pulled downward, the cheek then can be massaged upward into proper position.(Fig 23) It can be adjusted for symmetry and a natural appearance with the patient awake, in a seated position, checking for approval and satisfaction.(Fig 24, 25)

Whether this anchored thread will have the distinct advantages claimed over the free floating aptos thread, only time and clinical experience will tell us. Because it is FDA approved now, it will have a large following in the United States. It is, though, technique sensitive and does require proper training and experience.

Minimally invasive procedure correction of the aging face now includes the fourth R – Resuspension. This does open a new frontier for the dermatologic and cosmetic surgeon.