Marlen Sulamanidze / George Sulamanidze / Constantin Sulamanidze
Introduction The aesthetic manifestations of the aging process in the cheekbone, cheek and infraorbital areas are especially concerning for patients, so rejuvenating inter- ventions in these areas are most in demand.
Objective To introduce the experience of our clinic for aesthetic manipulation using Aptos (anti-ptosis) thread lifting methods in the midface area.
Methods Among the surgical interventions that we used were Aptos thread lifting methods both in combination with lower blepharoplasty, and without it. At the same time, special attention was paid to the individual approach, trying to minimize invasiveness and, most importantly, trying to achieve the effect of moving subcutaneous soft tissues to a new, more advantageous position from an aesthetic point of view, with their fixation to dense structures.
Results The results of application of the presented methods to lift the cheek–zygomatic and infraorbital regions using Aptos methods were studied. In the overwhelming majority of cases, the results satisfied both surgeons and patients.
Conclusions Aptos methods for lifting the midface soft tissues, which we used, are quite effective for rejuvenating the aging face.
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In the last 3 decades, aesthetic surgery on the midface area began to develop rapidly. There were always significant preconditions for this: patients and surgeons noted that the visual signs of facial aging are more sharply manifested in this area. Ptosis of the infraorbital soft tissues and buccal areas, fat hypotrophy, and consequently, appearance of the nasolacrimal furrow and infraorbital depression, aggravation of the nasolabial fold were always considered signs of a dull, sluggish, aging face. The increasing demand for interventions to eliminate such deformities encouraged surgeons to improve the classical and develop new meth- ods for contouring and lifting the middle zone of the face. Among them are endoscopic lifting, contour plastic implants, autologous fat, fillers, thread suspenders, skin peels, etc.
Possessing certain advantages, each of them has limi- tations that do not allow manipulation or operation in all cases, regardless of the volume and nature of the deformation.
From 2003 to 2008, for the lifting of flabby soft tissues in the middle zone of an aging face, several minimally invasive surgical techniques have been developed in our clinics, which are currently used in our daily practices. Among them are thread liftings—Aptos Thread 2G, Aptos Needle 4/0 and Aptos Needle 2G. This report presents the most frequently used operations and manipulations in our clinics as invasive, involving the application of a surgical incision, and without disrupting the integrity of the skin, through a puncture.
For all this time (6 years), 1226 operations were performed by the main author using the given methods. Aptos Thread 2G method—736 procedures, Aptos Needle 2/0 method—330, and Aptos Needle 2/G method—160 patients. From the total of 1226 patients, 1028 (84%) were women aged 30–60 years. The percentage of patients aged between 35 and 50 years was 67%. In our experience, this is the age group in which the best results are achieved by Aptos methods.
It is performed with the help of a special suture material, which consists of two needles (100 9 0.9), to the ends of which atraumatically is attached a thread with multidirectional barbs (prolene or a thread of polylactic acid 2/0, 25 cm long). The tips of the needles have a special oblique sharpening and joined together they make up one spear point, which allows the injection of both needles into the skin at a time through one puncture and to separate them at the required depth. Thanks to the realization of the original idea of pairing two needles, the operation was performed without incision and skin retraction (Fig. 1a, b).
The point of injection was determined in the projection of the zygomatic arch about 3–4 cm from the lateral cantus. The paired needles were inserted with a single point to the periosteum, and here they were separated and alternately were passed according to the marking (Fig. 2). At the same time, the fingers of a free hand pulled up soft tissues of the infraorbital, malar and partially buccal areas, creating a lifted, high contour of this zone, and the other hand pushed the needle. The needles and, accordingly, the threads were passed along the contour of the bowstring (video animation No. 1), i.e., after injection and separation, the tip of each needle was gradually deepened to the middle of the pull-up area and from there was also gradually lifted toward the dermis to the exit point near the nasolabial fold. Thus, the whole thread was passed in the SMAS of the molar and infraorbital regions, which usually corresponded to the projection of the nasolacrimal groove, thereby pushing out the tissues of the furrow itself more proximally achieving visual smoothing. After the removal of both needles, the soft tissues and the ends of the threads were pulled up, the remains were cut, and the tips were buried under the skin. At the same time, the bend of the thread slipped under the skin to the point of divergence of the needles, where it clung to the periosteum of the zygomatic arch. This adhesion significantly strengthened and stabilized the entire structure of the lifting effect of the midface zone, because the inflection of the thread did not engage the dermis, but slipped deeper to the point of divergence of the needles, and the skin retractions did not appear (video animation No. 2 and intraoperative video No. 1).
The given method was applied for lifting the soft tissues of the midface area, as an independent operation, so in com- bination with classical or transconjunctival blepharoplasty. These interventions were performed using a special sutur- ing material, which is a 6-cm-long curved needle with a smooth thread—prolene 4/0, 60 cm long (Fig. 3), attached to the needle in its middle part. This product has the ability of two-way patency, allowing to carry the thread under the skin and subcutaneous suturing of soft tissues along the oval in the form of a purse-string, round or elongated contour without skin retractions and obtaining a smooth tightened contour.
Depending on the degree of ptosis and the severity of the tissues, the presence of a lacrimal sulcus and the depth of its occurrence, we developed several modifications of the intervention for lifting of the infraorbital and cheek—malar areas, but in this report, we will consider the most fre- quently performed operations. Figure 4 shows the marking of an independent intervention, according to which, along the ‘‘crow’s foot’’ wrinkle, a 2–3 mm long incision was made, up to the periosteum of the eyebrow edge, then widened the duct with a thin mosquito-type clamp. The Aptos Needle 4/0 point was inserted into the given duct in such a way that it grasped the periosteum. The fingers of the free hand helped to place the tissues of the infraorbital and cheek–zygomatic areas in a tightened position, the needle was guided along the marked oblique contour, alternately extracting it and changing the point, turning it and returning to the wound. Here, both ends of the thread were tightened and tied to the periosteum with several knots. Similarly, the second and third sutures were applied according to the marking. All together, these multivectored, intersecting sutures created a new, high, aesthetically more favorable contour of soft tissues, with smooth transitions to neighboring areas (intraoperative video No. 2).
The same lifting was performed simultaneously with classical or transconjunctival blepharoplasty. In this case, suspension points of the three ‘‘purse-string suture’’ sutures were determined in different places of the arcus marginalis (Fig. 5).
The given method is performed using a special suture material that absorbed the positive qualities of Aptos Thread 2G and Aptos Needle 4/0.
This product is composed of a prolene thread or a 2/0 polylactic acid thread, 50 cm. in length, with multidirec- tional barbs converging to the middle part. The thread is connected to two double-pointed needles in their middle part by its ends (Fig. 6). The length of each needle is 10 cm. Also, like the Aptos Thread 2G, the needles are paired in such a way that one point can be punctured into the skin through one injection. In the depths of tissues, dividing the needles, you can pass each one separately according to the marking in different directions.
The combined tips of the Aptos Needle 2G were inserted according to the marking (Fig. 7) into the area of the zygomatic arch up to its periosteum, where they were separated and alternately passed through fatty tissue along the planned lines. The needles exited at the marked points partially, were turned and returned by another point to another trajectory. Thus, both needles, followed by a thread attached to them, bordered the area of the middle zone of the face in the form of two pursestring sutures, and the inflection of the thread in its middle part slipped to the periosteum of the malar bone and was firmly fixed there. Simultaneously with the passage of the needles and the moderate tightening of the threads, a high, lifted volume of soft tissues of the infraorbital and cheek–zygomatic regions was created with the fingers of the free hand. At the exit point of the thread ends and their final tightening, the excessive ends were cut off and buried under the dermis (video animation No 3). At the same time, there was no need for suturing, because the barbs along the entire length of the thread firmly fixed to the underlying fibers. Addi- tional fixation of the purse-string sutures was provided due to the stable engagement of the tissues with the inflection of the thread both in the zygomatic arch area and in the nasolabial fold region. Thus, they created a high even contour of the midface zone, eliminated the nasolacrimal furrow and somewhat smoothed the nasolabial fold, without producing skin incisions.
This technique proved to be more reliable than Aptos Thread 2G due to the creation of two pursestring constructions, 3 bends of the purse-string sutures and the diversification of lifting. This technique was also more effective than Aptos Needle 4/0, because it did not require skin incisions and surgical knots, and Aptos Needle 2G thread had barbs that evenly grabed soft tissues throughout its entire length.
In the overwhelming majority of cases, infiltration anesthesia was used in the above-mentioned operations and manipulations: Lidocaine Sol. 1% with adrenaline or epinephrine, but no more than 4–6 ml on one side, was injected along the markings.
Usually, any of the described operations were carried out easily and quickly, the tissues were inflicted with minor trauma, the result of the intervention was already visible on the operating table.
After the operation, sterile stipes were placed on the wound (or puncture) for 1–3 days.
The technologies of the presented methods were developed on the basis of clinical experience, studying the literature on topographic anatomy taking into account the age changes that occur in the aging process of the organism.
Soft tissues of the midface zone are fixed to the periosteum of the zygomatic bone and the lower edge of the orbit (arcus marginalis) by means of fibrotic folds, and also are suspended to the vascularneural bundle emerging from the canalis infraorbitalis. According to the modern morphological studies, these structures gradually weaken over time, atrophy and stretch. Soft tissues or so-called fat compartments are influenced by ptosis together with them, creating a new ‘‘landscape’’ of the midface zone skin. In our clinical practice, we have almost always noted that the periosteum of the upper jaw, zygomatic bone and its arch, and also of the neurovascular bundle change their position with time, they practically do not stretch and accordingly do not weaken. Only their connections with more mobile, loose structures, which include subcutaneous fat of the infraorbital and nasolabial areas are weakened and stretched during some period of time, thus ptosis of these parts is especially intensive. Probably, at a young age this fat aggregation constitutes two compartments of this face area and SOOF. The anatomy of the zygomatic area (the third compartment) is somewhat different: here the fatty tissue is tighter, penetrated with fibrotic folds and tightly jointed to the underlying periosteum, so clinically, this area is not highly prone to ptosis. Soft tissues of the infraorbital and buccal areas are partially supported due to the connections with the fatty tissue of the zygomatic area.
As a result of the weakening and stretching of the fibrotic folds and ligaments between the arcus marginalis and the infraorbital fat structures and, accordingly, ptosis of this part of the midface zone, a palpebromalar (in- fraorbital) furrow appears, aggravating the retraction near the ‘‘eyelid–cheek’’ border. Also, as a result of the weakening and stretching of the bonds between the zygomatic fat and the fatty tissue of the infraorbital area and accordingly, the ptosis of the latter, a nasolacrimal groove appears.
This is sometimes accompanied by the ptosis of the fatty tissue of the cheek and the appearance of a depression beneath the cheek fat. In this process, the hypotrophy of the fatty tissue of the infraorbital region is of a great importance too, a decrease in the volume of this zone significantly worsens the aesthetic effect of the whole face [14, 15]. As a result, the middle zone of the facial soft tissues is divided into three sections (a compartment)—the cheekbone, the infraorbital and the nasolabial, which are clearly manifested clinically. Due to the ‘‘sliding’’ of the nasolabial area of the midface zone down and medially (the first compartment), its hypertrophy also aggravates the nasolabial fold. The weakening of bonds and fibrotic folds between the cheek fat and the fibers of the cheek (buccal fat, Bichat‘s fat pad) and, accordingly, its ptosis gradually lengthens and deepens the nasolacrimal furrow.
Thus, instead of a single convex smooth contour of the skin of the midface area with smooth transitions to neighboring areas, i.e., the landscape of the young face, the zygomatic, nasolabial and buccal regions visually manifest themselves with age, and the suborbital region practically appears in the form of a retraction.
In accordance with these conclusions, we set the task of developing methods that would allow a ‘‘return’’ of the divided sections of the midface soft tissues to the ‘‘old’’ place, to unite them with new connections—thread sutures without surgical operation.
Due to our experience, the manual movement of all and each compartment of the midface zone, soft tissues freely and easily move upwards and laterally, so they do not need operational mobilization.
Taking the given circumstances into account, the mini- mally invasive Aptos methods have been developed, which, depending on the indications, allow linear, circular, purse-string, skeletal or elastic suturing of the soft tissue ptosis of the midface zone, their lifting and stable fixation to denser structures. Above we presented the techniques of the most frequently used manipulations.
Let’s analyze each of the presented methods of lifting the middle zone of the face and the results that can be obtained with their help.
According to the Aptos Thread 2G method, thread lift- ing of the midface zone is created due to a somewhat oblique but linear direction suspension to the periosteum of the malar bone arch and barbs on the thread. Tough sus- pension of the barbed thread occurs due to the flexure of the thread in this section.
When performing this manipulation, both threads were passed through dense zygomatic fat, under the nasolacrimal furrow and further into the nasolabial fat region. ‘‘Return’’ of nasolabial fat under the ‘‘patronage’’ of the zygomatic area was carried out due to manual transfer of soft tissues of this site and their threading on the barbs of the tightened threads. This eliminated the nasolacrimal furrow, aligned the contour and smoothed the nasolabial fold (Figs. 8a–d, 9a–f).
Manipulation according to this version also allowed moving and suspending tissues of not only the nasolabial but also the infraorbital and buccal areas to the periosteum, the arch of the malar bone and fatty tissue of the zygomatic area, increasing the volume of the raised tissues, and eliminating the nasolacrimal groove all along and smoothing the nasolabial fold (Figs. 10a–d, 11a–d).
The disadvantage of Aptos Thread 2G methods is the fact that although in the area of the zygomatic arch the attachment is fairly stable (due to the attachment to the periosteum of the inflection of the thread), the threads are passed linearly along a slightly curved path, and their ends do not attach to dense structures and remain in a free state.
This circumstance weakens the entire structure and, accordingly, the stability of the lifting—recurrence of aesthetic deformation, happens on average after 2 years. At the same time, of all the three methods presented Aptos. Thread 2G is the least traumatic and easy to perform for surgeons. Postoperative rehabilitation is shorter and therefore the technique is in demand among doctors and patients.
Therefore, in cases in which the ptosis of the tissues was more pronounced, when it was necessary to significantly move the skin-fat layers, the volume of tissues was large and when there was a need to have long lasting results (3–4 years or more), we applied Aptos Needle 4/0 or Aptos Needle 2G, which did not have free ends of the thread and created a rigid fastening of the lifted tissues at several points, due to the purse-string structure, which also had different vectors.
The Aptos Needle 4/0 method, as an independent operation, allowed suturing, moving and stable tissue fix- ation of the nasolabial and buccal fat tissues to the periosteum of the orbit margin in the projection of the lateral cantus, as well as the removal of the nasolacrimal fissure along its entire length and smoothing of the palpebral fossa and nasolabial folds (Figs. 12a, b, 13a, b).
The use of this technique in combination with blepharoplasty, along with the effects that were achieved by previous methods, made it possible to smooth out groove under the cheekbone fat, since sutures were fixed to the periosteum of the orbit margin throughout its entire length (Figs. 14a–g, 15a–f).
The nearest postoperative period proceeded smoothly (Figs. 14b, 15b, e, 24b). The usual phenomenon was swelling and hypercorrection. Hemorrhages, skin retractions at the insertion and exit points, contour irregularities of the skin, pronounced asymmetry, and inflammatory processes were rare. They were corrected along with the skin contraction and the distribution of soft tissues under the new conditions independently, by massage or administration of resorptive therapy and antibiotics. In rare cases, it was necessary to remove the threads (Figs. 19, 20, 21, 22, 23, 24a).
Our APTOS methods for lifting the midface soft tissues make it possible to achieve a new aesthetic harmony quickly, easily, accurately, reliably, with minor surgical trauma, with smooth contours of the skin surface, without skin retraction and do not require excessively careful postoperative management of patients. Another advantage is the possibility of combination with classical methods of lifting; moreover, classical methods can be performed in a more truncated, less traumatic way without damaging the result.
The described operations and manipulations, despite the seeming simplicity, require a good qualification of a specialist, knowledge of the anatomy of the middle zone of the face, a correct understanding of not only the aesthetics of the face, but also of the patient’s desires.
Compliance with Ethical Standards
Conflict of interest The authors declare that they have no conflicts of interest to disclose.
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