Elevating non-surgical facial lifting
Dr Roberto Pizzamiglio explains how Silhouette Soft sutures with bidirectional cones can be used for elevating facial tissue
Sutures with bidirectional cones provide a non-surgical treatment option for aesthetic doctors to elevate tissue without surgery. Some plastic surgeons may be apprehensive about using the technique—because the skin elevation is less dramatic than the surgical results they are used to achieving. However an increasing number are using it as a transitional treatment where patients are not yet ready for a full face lift, are contraindicated, when they don’t want to have a general anaesthetic or countenance considerable down time. With the appropriate patient selection it is being used to achieve impressive results.
The Silhouette Soft Lift
The Silhouette Soft Lift is a contemporary variation on the “traditional” thread lift, using specialised sutures which are introduced into the subcutaneous layer of the skin with a very fine needle, to lift tissue and improve skin texture. The idea is to “lift” the tissue with sutures interspersed with bi-directional cones, in a minimally invasive fashion, and is most suited to patients with mild ageing characteristics.
The ageing process brings about a three-dimensional change in the shape of the face. As we age, the fat compartment in the jaw drops, but we have retainer ligaments that maintain the aesthetic position of the jaw. Add to this a reduction of the bone and the relaxation of the tissue and the process brings about the changed look of our ageing jawline.
The active parts of Silhouette Soft sutures are the cones, which act as an anchoring system. When the Silhouette Lift was introduced in 2006 as a surgical procedure, the cones were a hybrid permanent suture, with resorbable cones designed to grasp the tissue. A totally resorbable bidirectional suture has since been developed and was launched in 2013. This advance enabled the suture to be used without the need for surgery as this kind of suture can be inserted in the subcutaneous tissue, and not in the dermis. The cones remain the same, creating an anchor to facilitate the tissue lift, but also allow compression of the fatty tissue.
The first sutures to be introduced featured eight bidirectional cones and two needles which were needed because the suture was inserted in two steps. The first insertion for the first half of the suture and first series of cones; the second needle to insert second half of the suture, from the same entry point.
Silhouette Soft has undergone an evolution, and now also features 12 and 16 cone sutures to enable the whole face and neck to be treated effectively. However the difference is not only the number of the cones on the sutures, but also the length of the area which is grasped by the cones—the distance between the nodes has increased from 5mm to 8mm, allowing a larger area of subcutaneous tissue to be treated.
The cones are fabricated from a mixture of polylactic acid and glycolic acid, and are absorbed by the body in around one year. The suture material is also made from polylactic acid which is absorbed in around two years. The collateral effect of the polylactic acid is stronger fibrous tissue production. Polylactic acid stimulates type III collagen, which is a structural and solid collagen. This builds around the cones and when the cones are absorbed, fibrosis around the knot remains and maintains the support of the tissue.
In terms of the “lift” effect, the suture does not produce a lift as such; it’s the movement and support of the tissue it brings about, which creates a fresher shape. For a patient who wants tightened skin, surgical intervention may be necessary as the suture procedure is designed to support the tissue in the appropriate position.
When using an eight-cone suture the distance between the two entry points must be 10cms. From the first entry point, the first half of the suture is inserted into the subcutaneous layer of the skin, followed by the second needle from the same entry point, and the second half of the suture in the opposite direction. The technique is versatile, enough to be used in an angled part of the face—for example to create traction in the jawline and create better refraction and improved jaw definition.
A longer suture would usually be used in a loop configuration rather than straight line. The 12-cone suture is 18cms and the 16-cone is 20cms. However, it is necessary to change from the bidirectional principle of the suture to the double unidirectional position of the suture because the cones work in the same direction. The technique for a longer suture is slightly different because two entry points are needed instead of one, but the way to insert the suture and the depth of the sutures remains the same.
Probably the most frequently treated areas are the mid and lower face. When these areas are treated in a straight pattern it is recommended that two sutures with the eight-cones are used for each area. When using eight-cone sutures we suggest using a minimum of two sutures to create enough support and compression of the tissue. Even in the jowl area of the lower face, two sutures can be used—for example one at an angle and one straight. These different vectors improve the jaw definition.
Adopting the new ‘U’ technique
Using a new advanced ‘U’ technique to configure the sutures provides several advantages. One advantage is that with one suture we can treat one area—for example just one suture can be enough to treat the jaw. The second is that the entry points are placed posteriorly, or sometimes behind or at the level of the hairline, so they are not visible. Using the ‘U’ configuration and the eight-cone suture, allows compression of the fatty tissue, so one can create more malar projection in the mid-face, if desired.
The ‘U’ technique also produces greater elevation of the tissues and less projection when the tissue is sagging, so can be more useful to reposition it in the right place. It is possible to work horizontally, but generally we change the vectors according to aesthetic outcome we are seeking, so we can stay more vertical or even cross the vector.
This technique can also create improvement of the upper part of the neck and better definition of the jaw. Whilst it’s not a neck ‘lift’ in the true sense, we can use the ‘U’ technique if skin tightening is required, or we can cross the mid-line when we have to support the platysmal bands. A 12-cone suture is useful here because of the dimensions of the neck, and if the neck is bigger, a 16-cone suture can be used.
The ‘U’ suture configuration also makes it possible to treat thicker skin successfully. The insertion technique starts with creating an entry point using an eight-inch needle. The hole is the same diameter, more or less, as the base of the cone and then from that hole the first needle of the suture is inserted.
To treat the brow, we work with two sutures—two eight-cone sutures in an ‘L’ rather than ‘U’ shape. The suture is inserted into the asymmetrical part of the brow because the distal cones have to grasp the soft tissue at the tail of the brow, and the proximal end of the suture goes to the temporal area and elevates the tail of the brow.
To insert the sutures correctly it’s essential that the first needle remains vertical. The needle has a mark at the 5mm distance from the tip that disappears when the tip is 5mms into the subcutaneous tissue. With Caucasian skin the average of the thickness between the epidermis and the dermis is usually 2.8mms. With thicker skin—for example with Asian patients—it could be 4-5mm, so you have to go deeper to be sure of staying in the subcutaneous tissue.
After inserting the suture, the tissue must be compressed. It’s a self-blocking suture—so doesn’t need to be fixed in any part—and the presence of the cones in the opposite direction collects the tissue over the centre of the suture. This increases the projection and the base of the cone will not release the traction. Staying a minimum of 5mm from the entry point, in the central part, ensures the suture is placed at the proper depth.
The ‘U’ technique uses two entry points—created with the same needle at the same time. The eight-inch needle can be inserted from the first point and can exit out of the second one, and we use the needle like a trocar. We can work in front of, or behind the hairline. Initially we suggest inserting in front to avoid fighting with the hair, but when one is more experienced behind the hairline so any puckering caused by the elevation of the skin—which lasts for one or two days—will not be visible.
We insert the suture in the adipose tissues, we compress the tissue and create elevation through mobilisation or compression of the tissue.
When inserting the sutures it is important to visualise the underlying position of the veins, arteries and nerves. A pinch to a vein can cause a haematoma and in the temporal area we have an artery, so of course there’s a more serious risk of hematoma here. Nerves, especially the three branches of the facial nerve, can also be a danger spot. For this reason it is important to pay particular attention to the temporal branch of the facial nerve, which is very superficial and usually on top of the superficial parieto-temporal fascia, between the superficial and the deep temporal fascia. The mandibular part and the zygomatic branches however are really deep, so it’s impossible to create any injury to these nerves because of their depth.
How to check the patient
Start by simulating the desired skin lift manually with your hands. If you see the anticipated result with a very moderate elevation of the tissue, it’s possible to obtain the same result by using the bidirectional sutures. Sometimes we want to treat the neck, but with the traction of the fingers we don’t see any result in the anterior cervical area. In this case, because of the fat, we would not achieve the desired results. If we have a fat problem, first we have to treat the fat and eventually after two to three months we can treat with the sutures.
The indications for treatment of the face with bidirectional sutures range from the brow to the neck including the nasal area—for aesthetic or functional purposes or for nasal valve collapse. In fact, wherever we want to mobilise the tissue, we can use the sutures. In the mid face using eight-cone suture fat compression, we can bring about malar projection and usually, between two to four months we observe an improvement in the result due to the contraction of the capsule around the suture and then it remains stable. After one and a half years to two years the result is less marked and a repeat of the treatment is needed.
In the neck we can achieve improvement of the cervical angle with the goal of creating better definition of the jaw, and this is more effective when treated in combination with the jaw area itself. We can also successfully treat the brow area.
The only rule is to be sure to work 5mm deep vertically inside and to check where the tip of the needle is every time. This is the way you can ensure that you are in a perfect plane. The tip of the needle has to be mobile and free – if we can elevate the tip of the needle we are in a safe level, because if you can’t elevate the tip, you are under the fascia. A traction of the skin due to the tip of the needle, means we are in the dermis.
Once the needle has been inserted under the skin it needs to be removed. The first four cones start to go into the tissue and we create a gentle contra-traction allow their correct positioning. Once the first four cones are embedded, we have to treat the second half, taking the second needle vertically by 5mm into the same entry point. Then we turn the needle to a horizontal position and we go through the proximal exit point, maintaining the same depth. Here we have less adipose tissue but we have to stay between the fascia and the dermis. If we can’t feel when the tip is near the exit point, it’s good to put the other needle on top of the skin and push down to see exactly where the tip is rather than going over the exit point and potentially creating an injury to the vessels in the temporal area.
By knowing where the tip of the needle is we know where the suture will be inside. When the second needle is inside the loop of the first suture is just visible, the first cones start to go in and we just have to perform the second contra-traction to allow the recession of the suture.
The best way to avoid complications such as breaks to the suture, dimples or bruising, infection or skin folds is to know which areas are contraindicated to treatment with sutures. The principal contraindication is the presence of fillers, but if you have any patient who has been treated with permanent filler and you feel the capsular, do not put the suture in the same area. Pinching to the capsular can also cause an unpredictable reaction. Other minor complications might include hardness, pain or parestasia for a maximum of one to two days.
In many cases suture treatment is not something we use to avoid doing something else, but in combination with other treatments. Most of the time when repositioning the tissues, we may also need to replace volume, so we can use the sutures as part of full-face non-surgical bio-revitalisation. We suggest combining treatments or using the bidirectional cone sutures a month before or after the volumisation procedure. This combination can give a notably more effective result compared with a single treatment alone.
The advantage of bidirectional sutures is that we can perform a non-surgical skin lift in our clinic. The treatment can be minimally invasive, using local anaesthesia and can be used to treat the face or body using the position of the suture to achieve our goals.
Dr Roberto Pizzamiglio has been Scientific Consultant and Teaching Course Director for Silhouette Lift since 2006 and more recently became the Director of Training for Silhouette Soft. He is considered to be a world expert in the Silhouette Soft procedure. Since 1997 he is has been based in Spain where he is Director of the Aesthetic Surgery Unit at the USP Hospital in Marbella. He is also a Professor of the postgraduate Masters in Cosmetic Surgery at the University of Padua.