Otolaryngol Clin N Am 38 (2005) 11091117

Facial Lifting with APTOS Threads: Featherlift

M.A. Sulamanidze, MDa, T.G. Paikidze, MDa, G.M. Sulamanidze, MDa, Janet M. Neigel, MDb,*
b

TOTALCharm, Clinic of Plastic and Aesthetic Surgery, Moscow, Russia Private Practice, 101 Old Short Hills Road, Suite 204, West Orange, NJ 07052, USA

As the human face ages, it is known to be characterized by uneven focal ptosis of the soft tissues of the frontal, infraorbital, zygomatic, buccal, mental, and submental areas. The fat tissue in the zygomatic area is closely connected to the skin and the arch of the zygomatic bone by the solid intersection of the supercial musculoaponeurotic system (SMAS) and is rarely sagging [1]. The subcutaneous fat of the adjacent areas (infraorbital, buccal, malar, and partially mandibular) is suspended from under the soft tissues of the zygomatic areas (Fig. 1). Therefore, the skin of a young person is smooth and even. Gradually, under the eect of dierent causes (eg, age, degree of development of subcutaneous fat, structural pattern of the subcutaneous fat with its relation to the SMAS, along with mimic and masticatory muscles), gravitational sagging occurs in the areas where the connections are weak or the inuence is more intensive (Fig. 2). Therefore, lachrymal grooves appear, the nasolabial fold deepens, and wrinkling starts to be more evident [2]. In addition, much importance in the causation of involutional alterations in the suborbicular areas is attached by some researchers [3] to the gradual sliding down of such formations as the suborbicular ocular fat (SOOF). In the lower portions of the face, the neurovascular bundle that originates from the mental orice of the lower jaw prevents sagging of the subcutaneous fat. In addition to the neurovascular bundle, a more or less solid adhesion of soft tissues along the lower edge of the jaw line prevents the sagging. The so-called overhanging of tissues appears along with wrinkles [4]. The surgical intervention of uplifting and excision of excessive skin is the radical solution to correcting these deformities.

* Corresponding author. E-mail address: jmn@eyelid.com (J.M. Neigel). 0030-6665/05/$ - see front matter 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.otc.2005.05.005

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Fig. 1. Diagram of a horizontal dissection through the subzygomatic and buccal areas. 1, Circular muscle of mouth; 2, nasolabial pleat; 3, buccal muscle; 4, oral cavity; 5, masseter; 6, SMAS; 7, large and small jugal muscles.

In 1974, craniofacial and then plastic surgeons began to implement surgery of uplifting soft tissues under the SMAS. The surgeons put forward a postulate on the role of aging eects and the facial skeleton. The bravest of them changed over to supraperiosteal as well as subperiosteal SMAS uplifting. Such operations were even possible with the help of endoscopic equipment [57]. Beginning at approximately the same time, rejuvenating the face and neck was attempted through dierent methods. Various types

Fig. 2. Same diagram, with involutional alterations. 1, Circular muscle of mouth; 2, nasolabial pleat; 3, buccal muscle; 4, oral cavity; 5, masseter; 6, SMAS; 7, tear trough; 8, large and small jugal muscles.

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of skin peeling and contour injection plasty of soft tissues with a variety of gels, along with skin reinforcement with special 20-karat golden threads, were performed [8,9]. Usually, the number of dierent methods described to solve a single problem suggests that few have borne the test of time, failing to win consensus. Surgical intervention on a much grander scale has been characterized by a lengthy rehabilitation period fraught with possible complications and the expectation that the eciency and natural appearance as well as the longterm results would not be comparable with the severity of the intervention performed [10]. If one lls in those wrinkles and folds with any implant, for example, hyaluronic acid gel, this can result in puness with unnatural contours, and the center of gravity of the face would be visually shifted downward. Using chemical peels makes it possible to obtain skin reduction, most notably of the supercial layers, but not tightening of the underlying abby tissues. This does not attain uplift or a new contour to the face. There is no doubt that one must retain these tissues in their old place before one can give the aging face a more juvenile appearance. The aim of the present study consists of improving the cosmetic outcome of surgical treatment of patients suering from facial ptosis, using a new specially designed suturing material, simplifying the surgical technique, and decreasing the severity and duration of the postoperative period.

Material and methods In our practice, we use a new technique of uplifting through suturing of abby soft tissues of the aging face with special suturing material and stable xation in a new esthetically advantageous position. This technique is performed with the help of a new suturing material that we devised and called APTOS (RF patent 2139734, International Priority PST/RU 99/00263, dated July 29, 1999). The APTOS thread can be made of a metal, polymeric, or biologic material that is biocompatible with the human body. During the manufacturing process, the smooth thread (eg, made of polypropylene) is constructed with dents, cogs, or barbs, thus creating slant edges with sharp ends (Fig. 3). These cogs enable the thread to travel one way with the soft tissues. After the thread is inserted under the

Fig. 3. Diagram of the longitudinal section of the APTOS thread with unilaterally directed cogs.

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Fig. 4. Diagram of the longitudinal section of the APTOS thread with bilateral (converging) direction of the cogs.

skin, the cogs prevent the thread from moving in the opposite direction. This creates a uniform and symmetric gathering of the soft tissues, which uplifts them and provides a new volumetric contour. To x the uplifted tissues in the required position, the thread is provided with variously directed (convergent) cogs that provide support and xation of the newly created contour inside the tissues (Fig. 4). The thread is inserted into the subcutaneous fat with the help of a guide, which is a long injection needle.

Surgical technique In most cases, local anesthesia is used; 1% lidocaine solution is administered intradermally in the area of the entry and exit of the guide and along the area of the guide passage located in the fat (average consumption of 0.50.7 mL for one thread). The guiding needle is used to punch the skin along the previously marked contour before the area of desired lift at the required depth and is brought out at the place needed beyond the area of desired lift. Then, through one of the needles orices, the thread with converging cogs is inserted to give the soft tissues an upward lift. After the needle is removed, the remaining thread xates the desired position of the tissues. If necessary, the ends of the threads are additionally pulled up. In doing so, each cog engages and supports a particular portion of the soft tissue. The threads smoothly shift and group the whole area of the soft tissues, which lie within the zone of the threads action. After this, the thread ends are cut and allowed to retract under the skin. To uplift separate portions of ptosed tissues, we have developed a special marking (Fig. 5). For example, lifting the buccozygomatic areas requires three threads to be passed under the skin from both sides: one long (8.5 cm) and two short (5 cm) threads, with the long one passed suciently deep within the fat tissue. After being stretched, this creates an uplift of the abby buccal tissues and a round contour of the skin. The short thread passed parallel to the long one is needed to maintain the eect created by the long thread and to provide a more convex contour of the skin in this area. The second short thread passed subcutaneously along a steep arch from the zygomatic area toward the cheek makes it possible to replace the overhanging

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Fig. 5. Diagram of marking soft tissues of the face and neck in lifting with the APTOS thread.

above the nasolabial fold not only upward but laterally toward the cheekbones, thereby giving a smoother appearance and decreasing the lachrymal groove (tear trough). To lift mental overhanging, we implant two long threads on each side parallel to the skin, not touching it from the inside, at a depth of 1 to 2 mm in the subcutaneous fat. Two APTOS threads (8.5 mm long) are passed in the submental area, improving the contour of the soft tissue of the subzygomatic areas. Depending on the patient and individual peculiarities, other variants of implanting the threads are possible. The routine procedure is easy and quick to perform and is accompanied by minimal injury to the tissues, with little swelling and bruising experienced. The outcome is seen immediately, with a minimal short-term postoperative period (if any) and minimal postoperative restrictions (no abrupt chewing or facial expression and no facials, microdermabrasion, or massage for 23 weeks). Since 1999, we have used the described technique on more than 250 patients; however, the present article deals with analyzing the outcomes of only 157 patients aged 22 to 77 years old (average age 49 years). Most of these patients were women (94.4%). Of these patients, 130 underwent the placement of APTOS threads as the only procedure. The other 27 patients had additional procedures performed, such as peeling, liposuction and undercutting wrinkles with the wire scalpel. The indications for correction of the contours of the face and neck with the APTOS threads were ptosis of tissues of the face and neck, a abby and at face, and poorly manifested esthetic contours.

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Fig. 6. Before (A) and immediately after (B) uplifting of the buccozygomatic areas.

Results and discussion For the most part, this method was used to remove ptosis of the buccozygomatic areas (62%), which is related to the fact that it is these involutional alterations that the patients mainly worry about. In addition, the eect of the operation in these areas is visible immediately after the intervention and is especially expressive as well as long lasting (Fig. 6).

Fig. 7. Before (A) and 2 weeks after (B) uplifting of the buccozygomatic areas plus blepharoplasty.

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Fig. 8. Before (A) and 4 months after (B) uplifting of the buccozygomatic areas.

The immediate postoperative period up to 14 days was uneventful in most of the patients (Fig. 7). Only in 4 cases (2.5%) did we observe thread disruption attributable to unilateral weakening of edges and threads emerging to the cutaneous surface, thus requiring their removal and performance of a secondary implantation. We did not consider the cases of hypercorrection (9.5%), linear hemorrhage along the passage of the thread (9.5%), or skin indraft at the entrance and exit sites (14.6%) as

Fig. 9. Before (A) and 6 months after (B) lifting of the whole face.

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Fig. 10. Before (A) and 12 months after (B) facial lifting plus skin peeling.

Fig. 11. Evolution of the face before (A), immediately after uplifting (B), 2 weeks after uplifting (C ), and 1.5 months after uplifting (D).

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complications, because all of these were easily corrected spontaneously or manually. No other complications or allergic reactions were noted. Initially, we invited the patients to return during the postoperative period to follow up the duration of the eect achieved; however, later on, we were convinced that in most cases, the patients were satised with the obtained outcomes, and they only returned to continue other treatment. Additionally, the surgeons involved were quite satised with the short- and long-term outcomes, because the latter were good as well as permanent (follow-up from 2 months to 2.5 years after surgery; Figs. 811); therefore, we chose not to look for the evaluation criteria of the operations performed. Mention should only be made that at various points, 12 cases (8.9%) required unilateral or bilateral implantation of additional threads.

Summary The use of the APTOS threads for lifting the tissues of the face and neck is a simple, conservative, cost-saving, and time-sparing procedure that leaves no visible traces of intervention on the skin. At the same time, the proposed technique proved ecient for correction of the jaw line and for lifting the abby ptosed tissues in involutional facial alterations. Our experience proves that the described method can be an alternative technique to the classic methods of lifting and contour plasty of the jaw line with various implants.

References
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