CHAPTER 62 The Thread Lift Using Barbed Suspension Sutures for Facial Rejuvenation

Vincent C. Giampapa, Hakan Usal, Oscar Ramirez

Surgeons and patients alike are constantly searching for methods of facial rejuvenation that can be performed with minimal tissue invasion, with the least amount of anesthesia, and with “no” downtime. This is the “holy grail” of aesthetic surgery. One of the latest procedures in this field is the barbed thread lift, although suture suspension during lifting has been successfully performed for over two decades. The original type of suture suspension for the midface and neck required an open or a semiopen procedure. Suture suspension worked because of the wide undermining and repositioning of the soft tissues in the elevated position, which was held over the long term by the sutures until scar formation allowed tissue reattachment in the new position. However, when suture suspension was applied in a percutaneous fashion, the general complaint was that the suture tended to act like a “cheese-cutting wire” that would eventually cut through the tissues and diminish the effect over a period of time. The reason this happened was that the sutures were smooth instead of barbed. The advent of the barbed suture represented a new concept in facial lifting because of the ability of barbed sutures to hold and support tissues along their entire length rather than just at the loop made by the smooth sutures. This mechanical advantage provided by the barbed suture permitted its use without the need for tissue undermining.

The barbed suture also makes it easy to insert in one direction and difficult to move in the opposite direction. Once the suture is introduced in the soft tissues, it can be lifted to a position in one direction and the barbs will theoretically prevent the tissues from drooping to their former, original position. Although in principle this made a lot of sense, the early configuration of the barbed sutures was not effective enough. Over time, surgeons modified and improved the configuration of the barbed sutures as well as the surgical principles evolved.

History of Barbed Sutures

In 1964, New Jersey physician J. H. Alcamo patented a roughened suture that offered resistance in one direction only. However, there is no reference to its clinical use. In 1984, Fukuda patented the surgical barbed suture.

The next important landmark was the work done by Russian cosmetic surgeon Marlene Sulamanidze, who, working with Georges Sulamanidze and Tatiana Paikidze from 1986 to 1998, studied a series of subdermal thread insertions using threads from 5 to 18 cm long. This is the first clinical report of the concept and technique of barbed sutures. They described the application of barbed sutures in the subcutaneous plane without undermining. They called their suture design Aptos (antiptosis) threads. These sutures were introduced in the United Sates under the name Featherlift sutures. However, the Featherlift design did not gain U.S. Food and Drug Administration approval until June 2004.

In the United States in the late 1990s, Gregory Ruff invented what is now called the Contour Thread. The difference between the Featherlift and Contour Thread sutures is that the former is a bidirectional, free-floating device that does not require specific anchoring, whereas the latter is a unidirectional barbed suture with needles attached to both ends. The Featherlift requires a hollow cannula for insertion and is not anchored to a fixed structure. It is a self-anchoring device with one barbed segment used to “lift” the lower tissues while the upper barbed segment provides support in a higher position. The first-generation Contour Thread had a unidirectional barb configuration and one needle attached to each end. One long, straight needle is used to thread the suture into the tissues to be lifted (e.g., cheek) and the other end is used to anchor the thread in a fixed structure (e.g., temporal fascia). Subsequently, Leung and Ruff patented other variations and configurations of sutures, such as bidirectional barbed sutures with different types of needles and suture lengths.

Biomechanics of Barbed Sutures

Not all barbed sutures are the same. The Aptos barbed sutures are made of 3-0 blue polypropylene with cogs that are relatively longer and thinner than the Contour Thread cogs (Fig. 62-1). The Contour Thread sutures are made of 2-0 clear polypropylene.

Figure 62-1 The Contour Thread. Bottom, Magnified barbed section of thread.

The Aptos thread is introduced using a hollow cannula of larger diameter than the suture, whereas the Contour Thread has attached needles of slightly larger diameter than the suture. Because the Aptos suture is inserted through a wider channel, this theoretically may make the cog engagement slightly looser. The Contour Thread needle also widens the channel through which the suture is placed. The flexible needle configuration of the Contour Thread allows the suture to be introduced in a zigzag fashion (Fig. 62-2), which in turn allows better anchoring of the barbs in the tissue. Biomechanical studies have also shown that the shorter the length of the barbs, the stronger their grip on tissues. The Aptos thread has longer barbs than the Contour Thread. Needle attachment at both ends, as well as the bidirectional barb configuration, gives the Contour Thread the additional versatility of permitting a change in direction at the end of the path to apply suture knots if needed or to anchor in a loop of the central, nonbarbed segment. The newest sutures feature a helicoidal distribution of cogs, offering an even better grip. A design still in development is an absorbable suture that can be used in semiopen or open methods of tissue lifting.

Figure 62-2 Optimized placement patterns.

As with all cosmetic surgery procedures, patient selection is the key initial decision in obtaining optimal results. The Contour Thread procedure fulfills the demands of cosmetic patients because it is a minimally invasive yet effective procedure. It offers significant improvement in facial rejuvenation with minimal downtime and potential complications.

Anatomy

There are four natural aging changes one needs to consider when seeking to rejuvenate the midface. These were originally described by Hester and colleagues (2000) and include (1) gradual ptosis of the cheek skin below the inferior orbital rim with descent of the lax lower eyelid skin (this creates a skeletonized appearance with hollowness around the infraorbital area); (2) descent of the malar fat pads with loss of malar prominence in projection; (3) a prominence and deepening of the tear trough area; and (4) a marked enhancement of the nasolabial fold. These anatomic areas have been called the triangle of youth (Fig. 62-3); a youthful facial appearance and contour can be retained by limiting the effects of aging in these areas.