Lift and rejuvenate
The ageing face can benefit from the use of toxins and fillers, however the use of of reabsorbable sutures with biodirectional cones can offer better results for some indications, explains Dr Kuldeep Minocha
There is a limit to what can be achieved using a combination of botulinum toxin and dermal fillers alone to help combat the signs of facial ageing. The current trend of continuing to add volume to the mid-face is beginning to significantly alter the way our clients look. This has not gone unnoticed by the media and is having a negative effect on the aesthetic industry.
In 2012, as an aesthetic physician, I was first introduced to the concept of a totally reabsorbable suture with bidirectional cones, forming the basis of Silhouette Soft technology. The concept of providing both a mechanical lift and tissue regeneration through type 1 collagen formation, without resorting to surgery, appeared to be an ideal solution for those who had crossed the injectable threshold. How often have we seen clients who gently pull up sagging skin on their face to soften the jowl and improve the contour of their jaw line or neck? With all the best will in the world no amount of filler or toxin is going to produce this effect without surgery.
The cone technology pioneered by Kolster, owner of KMI Inc, Corona, CA in 2005 has been the real breakthrough in the development of suspension threads. The 360-degree surface of the hollow cone (1.0mm x 2.5mm) creates a strong anchoring effect on the fibrous soft tissue. Collagen begins to form as early as day eight, in and around the hydrophilic cones when placed in vivo. The fibrous reaction around the cones creates a solid support within the soft tissue, ensuring no migration or extrusion. It was Dr Nicanor Isse who had the idea of inserting re-absorbable cones between retaining knots on a 3/0 polypropylene suture, leading to the development of Silhouette Lift, approved by the FDA in 2006 and soon after obtaining the CE mark.
Since 2006, Silhouette Lift sutures have had numerous applications including lifting of the mid-face and jowl, in the treatment of facial nerve palsies leading to paralysis, and with 2/0 sutures, to lift the adipose tissues in the gluteal area. Fundamental to its success was the secure anchoring of the suture to strong deep fascia, placing this procedure within the realm of our surgical colleagues.
As a physician evaluating any new treatment, the safety profile of a product is paramount. Silhouette Soft sutures are made of 100% poly-lactic acid (PLLA) and the cones a mix of poly-lactic acid (82%) and glycolic polymer (18%). We know that PLLA has been used in medical devices and implants for decades and that the degradation ratio of PLLA compared to other materials used in the production of sutures is much slower, therefore its benefits are longer lasting. The formation of type 1 collagen in response to PLLA has been long established.
Redefining the jaw line and reducing the jowl are some of the most common indications. Enhancing anterior malar projection, softening of the naso-labial and marionette folds using a variety of vectors has proved to be very successful using this unique technology. The addition of the CE mark for its brow and neck lift in July 2015 has officially extended the licensed indications.
The use of Silhouette Soft as an adjunct to muscle-relaxing injections (usually performed two weeks prior to thread insertion) and dermal fillers or collagen stimulators (can be injected before or after thread insertion) provides the clinician with a range of treatment modalities to improve the signs of facial ageing in the most artistic way.
The Ideal Patient
Choosing the ideal patient for the procedure is important. This is not a face lift, although it does provide repositioning of displaced fat and volume restoration. Patients with excessive skin in the mandibular region associated with thick skin, those with excessive skin due to advanced ageing and thin skin would be unsuitable for the procedure. Excessive skin in the mandibular region but with hypertrophic type ageing as well as patients with excessively thin skin with lack of fat tissue would also not get such good results.
Suitable patients would include those with mid-face ptosis, loss of malar volume, jaw line ptosis, neck relaxation and brow ptosis.
One way of evaluating the potential effect of the procedure is by lifting the tissue by approximately 1cm with your fingers placed proximally (i.e. at the insertion point) and checking to see if there is a significant difference made to the tissue distally (i.e. at the exit point). If this produces a positive effect the patient should do well with the Silhouette soft procedure.
Key to the technique being successful is the initial vertical insertion made at the entry point with an 18G needle prior to the injection of local anaesthesia. This allows easy passage of the smaller 23G needle, with attached thread and cones, to the correct depth in the subcutaneous fat of approximately 5mm (Fig 1).
The needle is turned horizontally through 90 degrees and guided through the subcutaneous tissue. Extract the needle through the first exit point. Gently pull it and by way of traction, the first series of cones will enter the adipose tissue. When the last cone is inserted (Fig 2), stop traction and start inserting the second half of the suture, by introducing the needle vertically in the same entry hole (Fig 3). This is vital, to avoid excessive dimpling of skin at the entry point.
Proceed in the direction of the second exit point (Fig 4), extract the needle and with a gentle pull the second series of cones are inserted in the tissue (Fig 5). The entire thread has now been implanted (Fig 6). Next is the modelling phase of the treatment. With the fingers of one hand, apply slight pressure on the tissue. At the same time, pull first on one end of the exposed suture, and then on the other, which ensures that the cones are in contact with the tissue and that a certain degree of compression is maintained.
Once adequate compression has been achieved, cut the exposed ends of the sutures at the level of the exit points (Fig 6).
A variety of sizes of threads and cones are available, including 8,12 and 16 cone threads. Using a combination of straight, angled and/or U technique insertion patterns the clinician is able to lift, support and sculpt descending facial tissues.
Red indicates entry points and blue indicates exit points.
Post-treatment advice includes avoiding physical exercise, dental surgery, facial massage and use of saunas for two to three weeks. Patients are advised to sleep in a supine position and elevated on pillows for the first three nights as well as refraining from excessive facial movements such as yawning in the first week.
Careful explanation to patients about what to expect immediately after their procedure is an important part of the pre-treatment consultation. Entry point depressions and puckering or folding of the skin are all normal sequelae and resolve within days. Bruising and occasional haematomas may occur. Rates of infection are very low, with only a dozen cases being reported worldwide to the International Medical Advisory Board, despite there being over 385,000 threads inserted worldwide.
As with most aesthetic treatments it is unadvisable to insert Silhouette soft sutures in the presence of acute or skin chronic diseases, permanent fillers, autoimmune diseases, pregnancy and breast-feeding, patients under 18 years of age or those sensitive to the materials used in the components of Silhouette Soft.
Since being brought under the Sinclair IS Pharma umbrella, structured and supported training has been the hallmark of introducing this new technology to clinicians. Full day workshops are organised for hands on practical advice and demonstration.
Delegates are also encouraged to attend the World Expert Meeting in Barcelona every October. A record number of 1500 delegates from all over the globe attended in 2015 for an educational event at the Javier De Benito Institute. The two day conference is devoted solely to the Silhouette Soft procedure and includes in depth anatomy lectures as well as numerous practical demonstrations of the latest techniques being used all over the world.
Introducing Silhouette soft threads into my practice as an adjunct to my existing treatment portfolio has certainly provided with me with a broader range of options to treat more challenging areas of the face and neck. The results continue to improve over three to four months as Type 1 collagen is produced and can last for 18 months. From the patient’s perspective offering a tailor-made treatment, under local anaesthesia, which produces natural looking results and can be performed in less than 60 minutes is immensely appealing.
Dr Kuldeep Minocha is a trainer for Sinclair IS Pharma and lead Aesthetic Physician at Absolute Aesthetics based in London and Surrey.