Rejuvenating the Face

Commentary on: Rejuvenating the Face: An Analysis of 100 Absorbable Suture Suspension Patients

Published in Aesthetic Surgery Journal, Volume 38, Issue 6, June 2018, Pages 664–666

Kemal Tunç Tiryaki, MD

We are now seeing younger patients consulting for facial surgery. This patient group is neither in need of, nor interested in, extensive invasive procedures. Even though younger people usually do not require dramatic changes in their appearances, they still seek significant improvement of their signs of aging. If they are asked about their goals, most young people wish to achieve natural results with less surgery, less risk, and minimal downtime. In our necessary quest for increasing evidence-based medicine for less invasive facial aesthetic surgery outcomes, the authors of “Rejuvenating the face: an analysis of 100 absorbable suture suspension patients” have performed a meticulous evaluation of a large prospective series of patients for less invasive facial rejuvenation, which is commendable.

In this work, precious data is presented to assess the safety, efficacy, and patient satisfaction of an absorbable suture suspension system (Silhouette InstaLiftTM, Sinclair Pharma, Irvine, CA). It is noteworthy that in a relatively old patient group (average age, 61.6 years), the authors achieved high objective and subjective satisfaction rates. High satisfaction rates seem to be valid, particularly for the improvement in the midfacial area. To the authors’ credit, their results appear quite natural and show significant improvement, particularly in the midfacial area. On the other hand, in nearly a quarter of the patients, the results were assessed as inadequate. Interestingly, each of these 20 patients was having concerns about the neck region.

Although I congratulate the authors’ attempts to objectively examine the outcomes in less invasive facial rejuvenation of the aging face, there are several factors that are worthy of discussion:

First and most obvious, with a 6-month follow-up, it is not justifiable to conclude that the results are satisfactory. To be able to justify a surgical procedure, regardless of whether it is more or less invasive, there should be comparable data with the surgery showing long-lasting results.

Second, the success of the midfacial improvement in terms of shape and volume with nonabsorbable barbed sutures and other less invasive techniques is extensively discussed in the literature. Various authors have stated repeatedly that this improvement is due to volume redistribution rather than volume restoration. In my opinion, it seems to be a far-reaching claim to conclude that the improvement in the midfacial volume deficit is due to collagen production, which is stimulated by polyglycolide/L-lactide (PLGA) and Lactide glycolide. It might be true that there is collagen growth surrounding the cones and adjacent knots, but the amount of collagen would be negligible.

Third, it is very noteworthy that all inadequate results are in the neck region. This would confirm my subjective prejudice that suspension for the neck and midface have different mechanisms of action. In the midface, the success is achieved by collecting the malar tissue together, which necessitates much less suspensive power. However, in the neck, the threads are expected to hold against tissue movement and to resist gravity. In our experience, the major reason for unfavorable results with suspension techniques is that these threads are designed as single-point/single-line suspensions, in which the traction forces cause the ripping of the tissue at the anchor points. This is particularly true for the neck region, where the gravity is an added major counter-force against the vector of suspension.

Although I certainly agree with the authors that the structural integrity of the cones and knots are superior to barbed sutures, and that anchoring is stronger because they are designed to capture the retaining ligament instead of the dermis, I would argue that to be able to deal with gravity, loop suspensions would be more effective and longer-lasting.

The long-lasting affectivity of open\closed loop suspension techniques has a firm physical explanation: by creating a carrier loop in the tissue, we basically utilize tissue resistance against itself to balance the sheer forces. The force vector effecting one point on the loop is counterbalanced by another one in the opposite direction. Therefore, the more perfect the loop is, the less sheer force will be effecting opposing suspension-tissue junctions (Figure 1).

Force diagrams on the loops. (A) In single-point suspensions, the traction forces cause ripping of the tissue at the anchor points and suspension points. (B) In loop suspensions, on the other hand, the force effecting one point on the loop is counterbalanced by another one on the opposite side. The better the loop that can be created to carry the tissue, the less sheer force will be effective on each point on the loop. Reprinted with permission from Oxford University Press.

Force diagrams on the loops. (A) In single-point suspensions, the traction forces cause ripping of the tissue at the anchor points and suspension points. (B) In loop suspensions, on the other hand, the force effecting one point on the loop is counterbalanced by another one on the opposite side. The better the loop that can be created to carry the tissue, the less sheer force will be effective on each point on the loop. Reprinted with permission from Oxford University Press.

Finally, the financial cost of the proposed products that are necessary to perform the related techniques will be a major drawback of the surgical device-based suspension methods.

In summary, I would like to congratulate the authors for their work to objectively evaluate their results in less-invasive rejuvenation of the aging face. In properly selected patients, suspension techniques do work and provide comparable, sometimes better results to surgery. It is the quest of the plastic surgeon to analyze, assess, and understand why some suspensions work and some do not, as well as determine where they perform better and where they produce unsatisfactory results. As once we did for face-lifting surgery.

Hopefully, the authors’ investigation will stimulate further study on this important and evolving subject to provide more objective, evidence-based data to improve long-term results with less-invasive approaches.