National report — Minimally invasive procedures provide a wealth of lift options for patients, and the trend will continue, Sorin Eremia, M.D., tells Dermatology Times.
"Patients are demanding procedures with less downtime. Patients who have traditional lifts are concerned with visible scarring or displacement of the hairline, which severely limits hairstyle choices. We can now offer invisible scars with pure suspension lifts, and shorter, less conspicuous scars with modified, suspension suture-assisted lifts," says Sorin Eremia, M.D., associate clinical professor and director of cosmetic surgery for the division of dermatology at University of California, Los Angeles.
"The big breakthrough in pure suspension lifts was the tissue anchoring sutures, using tiny barbs based on the invention and early work on wound closure by Duke University plastic surgeon Gregory Ruff, M.D., or using larger, knotted multi-anchors, which I developed," he says.
"The new barbed and multi-anchor sutures have allowed for not only the exciting but yet long-term unproven concept of pure suspension (no skin excision) lifts, but also for improved results with more conservative facelifts. Smaller incisions, shorter skin flaps, and less invasive SMAS-platysma elevation seem to be possible by adding the suspension sutures to a more conservative face lift," he adds.
"The distal end of the unidirectional barbed 2-0 polypropylene (permanent) suture has a larger, long needle attached for pushing the suture through the skin, thus requiring an exit hole. The suture is placed through small incisions made in the hairline, and the proximal end is sutured to fascia. The tissues are manually elevated as desired and hang into position by the tiny barbs that grab on to the underside of the dermis," Dr. Eremia says.
Dr. Eremia's Anchor Suture was then introduced. "The key to this large multi-anchor suspension suture is a simple instrument that allows its placement from a single small incision hidden behind the hairline. The suture is placed much deeper, just above the SMAS. The bits of knotted sutures open up and deploy like anchors and grab onto the deep subcutaneous fat. This allows for marked elevation of the tissues, which are then suspended up to fascia, and there is no second exit hole," he says.
Some physicians, including Daniel Rivlin, M.D., a dermatological surgeon in Miami, use the two sutures combined for selected patients, with the Anchor Sutures deeper and the Contour Threads more superficial. This technique may well be a wave of the future, Dr. Eremia says.
"One important concept to evolve in the past 10 years is that the aging process causes loss of and displacement of volume. Loss occurs through tissue atrophy, displacement through stretching of fibrous support structures, and resulting ptosis and flattening of curved contours."
"The modern concept for restoration of a youthful appearance is to combine replacement of volume with repositioning of the ptotic tissues back to original positions. Suspension sutures help reposition, and energy sources induce collagen and elastic tissue regeneration and dermal tightening," he says.
Improvements in traditional fat grafting, early work in the development of tissue-cultured adipocytes for transplantation, and an explosion in the number and variety of tissue fillers - both recently approved and in the Food and Drug Administration (FDA) pipeline - will greatly increase volume replacement options, Dr. Eremia predicts.
According to Dr. Eremia, combined use of suspension sutures with nonablative resurfacing and volume augmentation, via fat grafting or use of commercial products, will likely be popular in the future.
"There is tremendous demand for low pain, minimal recovery time, and rejuvenation, and the industry is striving to achieve these goals. Patients are thrilled with shorter recovery time of six to 10 days, increased safety, and lower costs. However, many experienced facelift surgeons are still skeptical of long-term results, and proper patient selection is critical."