The moderate ptosis and flabbiness of the soft tissue and skin of the face and body areas like buttocks, breasts, inner thigh etc. have previously been treated with surgical excisions methods. There is a new era of Scarless thread and suture lifting methods.
The use of APTOS threads , polypropylene or metallic with unidirectional cogs or sharp edges, created by Silamanidze at al. 1 allows the gathering of the soft tissues in the face , creating lift and volume contouring in the face . The technique is simple, with insertion of the threads in the desired positions with a long injection needle as a guide.
Serdev suture methods 2 use another idea to lift and fix stable fascial tissue in any possible place of the face and the body using semi-elastic Bulgarian long-term (3-5 years) absorbable antimicrobial polycaproamide threads and special needles. They allow to suture and lift stable fibrotic structures such as the SMAS on the face, the trabecular system of the buttocks, the breast fascial tissue to other immobile stable fibrotic structures like fascias, tendons, ligaments etc.
Using different threads, tissues, areas and ideas, both Aptos and Serdev sutures are scarless and sparing methods to obtain lifting and volume contouring effect of the soft tissue with excellent and long-lasting results.
1. APTOS THREAD LIFT
I nvolutional alterations have previously been considered to be due the aging process of the integument. The solution consisted of lifting and excising the excess skin. Since 1974, such operations have been complemented by lifting the soft tissues under the SMAS .(7 ) Some surgeons have postulated a role of the facial skeleton in the aging process and have devised supraperiosteal and subperiosteal SMAS lifts especially with endoscopic equipment (4 freeman ,7 De la plaza ,8 Hamra ) Facial and neck rejuvenation now includes skin peeling, contour injection of a variety of gels, and skin reinforcement with 24-karat golden threads .(9 Adamjam ,10 Sulampredposl ) Filling in folds and wrinkles with injectable materials can result in a pasty-appearing, puffy face with unnatural contours. Skin peeling results in skin tightening but does not lift tissues or form a new contour Usually a combination of procedures is utilized to solve a single problem. Major surgical operations are characterized by a difficult rehabilitation period fraught with possible complications; the outcome may be worse than expected. Good results appear to be obtained by individual outstanding and experienced surgeons, but not necessarily in all their cases.
The authors of the Aptos thread lift M.A. Sulamanidze at al. have devised a simple surgical method, with specially designed suture material, to relieve facial soft tissue ptosis and decrease the duration and problems of the postoperative period. APTOS ("antiptosis," APTOS, Moscow, Russia) threads have been used since 1999. material "APTOS "(11 patent ), made of a bio-compatible metal, polymeric, or biological material. The smooth thread is manufactured with dents (cogs) that create slanting edges with sharp ends ( Fig. 1 ). The cogs provide unidirectional traveling of the thread through soft tissues that prevents movement in the opposite direction to the insertion. This provides a uniform and even gathering of the soft tissues, creating lift and volume contour. The thread is provided with convergent cogs (variously directed) that fix the lifted tissues in the required position and provide support and fixation of the new contour (Fig. 1 ). Thread is inserted with a long injection needle as a guide.
Usually local infiltration is used with a thin-gauged needle: 1% lidocaine solution in the area of entry and exit of the guide and along the passage in the fat. Average use is 0.5-0.7 cc for one thread.
The guide needle is placed through the skin, along the preliminarily marked contour at the required depth, and brought out at the exit point. The thread is threaded through the needle with the converging cogs and the needle removed. This fixes the thread in the desired position in the tissues. The ends of the thread may then be pulled up so that each cog engages the soft tissue. This allows shifting and grouping of the soft tissues within the zone of the thread's action. The ends of the thread are cut below the skin surface.
Separate portions of the ptotic tissues require special markings for lifting (Fig. 2 ). Lifting the buccozygomatic area requires three threads to be passed under the skin from both sides, one long (8.5 cm) and two short (5.0 cm). The long one must be passed sufficiently deep within the fat tissue, like a bow-string, that, when stretched, provides the effect of lifting the flabby buccal tissues and gives a round contour to the skin. The inferior short thread passed parallel to the long one is needed to maintain the effect created by the long thread and to provide a more convex contour to the skin. The superior short thread is passed subcutaneously along a steep arch from the zygomatic area towards the cheek. This lifts the overhanging skin above the nasolabial fold upward and laterally, removing the lachrymal groove.
Mental overhang is treated with two long threads on each side at a depth of 1-2 mm . T wo long threads implanted in the sub-mental area improve the contour of the soft tissues of the subzygomatic region (Fig. 2 ).
FIG. 1 . The immediate postoperative period is usually uneventful . Silamanidze at al. describe 2.5% of disrupted threads and threads emerging through the skin surface that required removal and secondary reimplantation , o vercorrection in 9.5%, and 9.5% of cases with linear ecchymoses along the passage of the threads. Skin inversion at the entrance or exit of the threads is reported to be 14.6% of patients , corrected spontaneously or with manual intervention. 8.9% required unilateral or bilateral implantation of additional threads. Most cases showed excellent improvement in the ptotic tissues (Figs. 3-4 ).
FIG. 2 . Diagram of marking soft tissues of the face and neck in lifting with the APTOS thread. I. The long thread is passed in a bow-string shape that lift tissues when stretched. II. Short thread is passed parallel to the long one to provide a more convex contour of the skin. III. Second short thread is passed subcutaneously along a steep arch from the zygomatic area toward the cheek.
FIG. 3 . A. Preoperative patient with ptotic bucco-zygomatic areas. B. Postoperative view immediatley following surgery.
FIG. 4 . A. Preoperative patient with ptotic bucco-zygomatic regions. B. Two weeks postoperatively after insertion of threads and blepharoplasty.
2. SERDEV SUTURE LIFTS
2.1. IN FACE ( Temporal, medial and lower SMAS and platysma lift, Brow lift, Chin enhancement)
2.2. IN BODY AREAS (Breast lift, Buttock lift, Inner thigh lift, Abdomen stretching etc.)
The s.c. “Serdev suture” is different in concept but same scarless and uncomplicated in the postoperative period. The idea is, using a curved elastic needle and a semi-elastic thread, to fix higher the SMAS, trabecular system or subdermis to stable fibrotic and fascia structures : IN FACE - such as facial SMAS (galea, zygomatic SMAS extension, check SMAS, platysma, or subdermal skin layer) to the non movable temporal fascia, coli fascia or mastoid periosteum; IN BODY AREAS – BUTTOCKS - the trabecular and fascial system to the sacrococcigeal fascia, IN BREAST – the breast tissue to pectoralis major fascia or tendon; IN INNER THIGHS – the subdermal inner thigh tissue to m. gracilis tendon etc.
The most important idea in the upper face is to lift the lateral face temporally (lateral eyebrow, lateral cantus of eyes and mouth). In art and theatre, faces called “mask of tragedy” and “mask of comedy” are well known and used to express age and status. The concept of scarless su ture lift in face is to turn the “mask of tragedy” into a “mask of comedy”, i.e. to lift up “the subcutaneous facial mask” – the SMAS. Since soft tissue and skin are attached to the SMAS, the lifting of the SMAS in temporal direction reflects in lifting of the face and its most important elements in the same direction (Fig. 5 ).
FIG. 5 . Mechanism of pulling the SMAS facial mask from one point. Effect on the facial structures.
Structuring and positioning different face elements could be used not only in face ptosis of elderly individuals. Aesthetically wrong face angles could enhance a sad look also in young patients. Fixing the SMAS in a higher position aims repositioning of other s tructures as well. Changing the position of the SMAS could restore the aesthetic angles, shape and proportions as a basis for beautification and rejuvenation, to give a happy, youthful appearance and a smiling expression not only to the elderly. With young patients the aim of the “temporal SMAS lift” should be beautification, based on face aesthetics (Fig. 6 ).
FIG. 6. A . Before and B. after scarless surgery. Temporal SMAS lift changes hanging angles of the eyebrow tail, lateral cantus of the eye and oral commissure. Better expression of chick-bone prominence is obtained , due to the lifting of the skin and the fat pad. Additional rhinoplasty is made to correct the “golden dividing” of the facial proportions in 3 equal parts; Lip augmentation to equalize lip and eye-with - eyebrow volume; Chin augmentation to obtain the “beauty triangle” and the straight line of the profile. Embellishment of the face is obtained and “smiling” expression is present ( the “ mask of tragedy” is changed into a “mask of comedy” = fresh and young look).
FIG. 7. A . Before and B. after lower SMAS-platysma lift. A. Thin and loose skin in the lower face. Gravity on soft tissue and skin is visible in different positions. B. The SMAS and attached to the SMAS soft tissue and skin are tightened. No gravity signs on the soft tissue and skin are visible - in any position. Lovely youthful "hungry cheeks" pleased the patient.
А) B) C)
FIG. 8 . A. Before, B. immediately after chin enhancement and tip rhinoplasty (columella sliding) to obtain a straight profile and aesthetic proportions of the face. (Intra op : Betadine desinfection still not washed up.) A slender neckline obtained is recognized as an attractive feature of youth. C. 5 years later. It is difficult to find any change in the operated chin position during the 5 year follow up.
FIG. 9 A . Before (Betadine disinfected) and B. after correction of the chin position and nose deformity in one session. The chin is sutured to the left.
FIG. 10 A . Before and B.Chin sutur ed to the left to treat the deformity of the face.
Fig . 11 . A. Sagging loose buttock soft tissue, dropping between the thighs, often depresses ladies and they ask for buttock lift. B. The lift of hanging buttocks has an aesthetic goal and elongates optically the legs.
A) B) C)
Fig. 12 . A, B, C. Three steps minimum are necessary for a complete fixation of the buttock superficial fascial system. It realizes a stable fixation of the lower buttock soft tissue to the upper area of the stable gluteus fascia.
A) B) C)
Fig. 13 . A. The patient before total UAL of body and lower extremities. UAL was performed two months before the buttock lift by suture for total body and leg beautification as well as to reduce the heaviness of the hanging buttock soft tissue. Back view of the same patient before UAL of body and extremities; B. Buttock lift by suture: result on day first after surgery (back view): Buttocks are softly lifted, the subgluteal is raised and shortened; C. Buttock lift by suture: result on day first after surgery (profile view). "Happier" buttock form and elongation of the legs is visible. The closeness of the wounds to the anus area makes antibiotic prophylaxis and strict hygiene obligatory.
Serdev suture is using simple steps: 1) The needle is introduced through a puncture of the skin in the selected direction (for example: Fig. 12 a, b, c); a bite or a zig-zag sewing through of the SMAS is done and the needle is brought out at the exit point using a second skin puncture . The thread is introduced in the hole of the needle tip and the one end of the thread is pulled out with the needle. Using same skin punctures, but a different way through the fibrotic tissue or SMAS, the needle pulls out the second end of the thread that provides a circle of the thread, fixing stable structures. The tightening of the suture is done under medium elastic pressure . Thus, the whole SMAS of the face is stretched and pulled up in temporo-occipital direction. 1/ In Temporal SMAS lift - t he galea, presenting the temporal SMAS , is fixed higher to the temporal fascia ; 2/ in Medial SMA lift - the buccal fat pad - to the temporal fascia; 3/ In the Lower SMAS-platysma lift - the cheek SMAS and the platysma - to the periosteum of the masthoid retroauriculary; 4/ In Brow lift - the subdermal skin layer of the eyebrow – higher to the frontal muscle fascias; 5/ In Chin enhancement - the chin soft tissue is fixed in a circular suture; 6/ In Breast lift the upper breast tissue is fixed to the pectoralis fascia and tendon; 6/ In Buttock lift – we make a circular suture to obtain a “bouquet” or bunch of the trabecular system and fibrotic soft tissue that we fix to the sacrococcigeal fascia each side. In each area we can use 2 skin punctures (in brow lift, chin enhancement, cheek-bone lift, lower cheek SMAS and platysma lift, breast lift, inner thigh lif), or 3 punctures(in medial SMAS face lift, breast lift and buttock lift), or 4 skin punctures (in temporal lift) in order to fix together parallel bites of fibrotic structures and to tighten them together under elastic tension to obtain a raphe or duplication. Usually no dressing s are necessary . P hotograph s before and after in face, profile and ¾ approve the aesthetic result .
FIG. 8 A,B . Before and immediately after a temporal SMAS lift and secondary rhinoplasty. The absence of visible signs of operation permits immediate return to social life.
FIG. 9 A,B. Before and after a temporal SMAS lift in upper lid ptosis . Visible elevation of the upper lid, the eyebrow tail and the lateral cantus of the eye reduction of the crow's-foot wrinkles , elevation of the cheeks' fat pad into a better cheekbone prominence; tightening and beautification of the skin.
Sequels are very rare. Attention has been paid not to insert hair in the subdermal tissue. Edema and bruising occur in less than 2 %. Less than 1% aesthetic disappointment is due to subjective un satisfactory effect of lifting angles .
The operation s with APTOS threads and SERDEV SUTURES are easy and quickly performed in outpatients under local anesthesia . The result is immediate and visible at the end of the procedure. Rehabilitation is short term, although muscle work in the operated area should be avoided for 2-3 weeks. I n dications include any ptosis of the soft tissues , flabby, flat face or buttock. The aim is to restore the aesthetic contours.
With Aptos m ost often ptotoc buccozygomatic areas were treated (62% of patients) .
With Serdev sutures, the most attractive areas in the face are the temporal, medial and lower face and neck. P atients are mainly concerned about their eye ptosis, lower face and neck flabbiness but also in their total body proportions and contour. In the body areas Serdev suture methods give unique opportunities to lift flabby and flat buttocks, small and medium ptosis of breasts and inner thigh. Abdomen is another area to be stretched with Serdev sutures.
The use of APTOS threads and Serdev sutures for lifting ptotic tissues and to obtain volume are simple c onservative procedures with skin punctures only, tha t leave no visible scars. Th e s e procedure s can be used as an alternative to the classic techniques of facial cosmetic surgery for ptotic tissues and contouring. Buttock, breast, inner thigh lifts give a new perspective in non scaring beautification cosmetic surgery.
“APTOS” & “SERDEV” SUTURES REFERENCES
Sulamanidze, M.A., Shiffman, M.A., Paikidze, T.G., Sulamanidze, G.M., Gavasheli, L.G. Facial Lifting with APTOS Threads. Int J C osm S urg A esth D erm, 2001 : 4.
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5. Sulamanidze, M.A., Paikidze, T.G., and Sulamanidze, G.M.: Flabby, ageing face-a new approach. Presented at the World Congress on Aesthetic and Restorative Surgery, Mumbai, India, Feb. 10-12, 2001:54 (abstracts).
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9. Adamian, A.A.: Clinical aspects of facial skin reinforcement with special (gold) surgical filaments. Ann Plast Reconstr Aesthet Surg 1988;3:18-22.
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11. "APTOS": RF patent #2139734, International Priority PST/RU 99/00263, July 29,1999.