Elimination of Aesthetic Deformations of the Midface Area ... Sulamanidze article.pdf · Keywords...
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ORIGINAL ARTICLE FACIAL SURGERY
Elimination of Aesthetic Deformations of the Midface Area OurExperience
Marlen Sulamanidze1,2 • George Sulamanidze1,2 • Constantin Sulamanidze1,2
Received: 15 September 2017 / Accepted: 18 February 2018
� Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2018
Abstract
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.
Level of Evidence IV This journal requires that authors
assign a level of evidence to each article. For a full
description of these evidence-based medicine ratings,
please refer to the Table of Contents or the online
Instructions to Authors www.springer.com/00266.
Keywords Midface � Face lift � Nasolacrimal furrow �Nasolabial fold
Introduction
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, aggrava-
tion 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 defor-
mation [1–8].
Electronic supplementary material The online version of thisarticle (https://doi.org/10.1007/s00266-018-1112-3) contains supple-mentary material, which is available to authorized users.
& Constantin Sulamanidze
[email protected]; [email protected]; [email protected]
1 Limited Liability Clinic Total Charm and APTOS Company,
Moscow, Russia
2 Limited Liability Clinic Total Charm and APTOS Company,
V. Orbeliani str. 18, Tbilisi, GA 0105, USA
123
Aesth Plast Surg
https://doi.org/10.1007/s00266-018-1112-3
Materials and Methods
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 [9–11].
For all this time (6 years), 1226 operations were per-
formed 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.
Aptos Thread 2G Method
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 multidirec-
tional 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).
Operation Technique
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
Fig. 1 a Aptos Thread 2G for
suturing soft tissues of the
infraorbital and cheek–
zygomatic areas (scheme).
b Jointed needles Aptos Thread
2G
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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).
Aptos Needle 4/0 Method
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.
Operation Technique
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 multi-vec-
tored, intersecting sutures created a new, high, aesthetically
Fig. 2 Marking scheme for suturing soft tissues in the middle zone of
the face Aptos Thread 2G
Fig. 3 Aptos Needle 4/0 for suturing soft tissues of the infraorbital
and cheekbone areas
Fig. 4 Marking scheme for suturing soft tissues of the midface area
using Aptos Needle 4/0—an independent operation
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more favorable contour of soft tissues, with smooth tran-
sitions 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).
Aptos Needle 2G Method
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.
Operation Technique
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 alongFig. 5 Marking scheme for suturing soft tissues of the midface area
using Aptos Needle 4/0—simultaneously with blepharoplasty
Fig. 6 Aptos Needle 2G for suturing soft tissues of the infraorbital
and cheek–zygomatic regions (scheme)
Fig. 7 Marking scheme for suturing soft tissues of the midface area
with Aptos Needle 2G
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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 purse-string 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, with-
out producing skin incisions.
This technique proved to be more reliable than Aptos
Thread 2G due to the creation of two purse-string con-
structions, 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 epi-
nephrine, but no more than 4–6 ml on one side, was
injected along the markings.
Fig. 8 a, b, c, d Patient P: 38-year-old, before and 3.5 years after correction of the midface area with Aptos Thread 2G
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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.
Results and Discussion
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
Fig. 9 a, b, c, d, e, f. Patient L: 50-year-old, before and 2 years after correction of the midface area with Aptos Thread 2G
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changes that occur in the aging process of the organism
[12, 13].
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 vascular-neural 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 con-
nections 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 weak-
ening and stretching of the bonds between the zygomatic
fat and the fatty tissue of the infraorbital area and,
Fig. 10 a, b, c, d Patient S: 35-year-old, before and 1.5 years after correction of the midface area with Aptos Thread 2G
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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
Fig. 11 a, b, c, d Patient T: 32-year-old, before and 1 year after correction of the midface area with Aptos Thread 2G
Fig. 12 a, b Patient C: 50-year-old, before and 2.5 years after suturing the midface area with Aptos Needle 4/0
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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.
Fig. 13 a, b The same patient
cFig. 14 a, b, c, d, e, f, g Patient H: 54-year-old, before, immediately
after intervention, 1 year and 5 years after classical lower blepharo-
plasty and correction of the middle zone of the face with Aptos
Needle 4/0
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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.
Fig. 15 a, b, c, d, e, f Patient E: 40-year-old, before, 20 days and 1 year after suturing the midface area using Aptos Needle 4/0 simultaneously
with transconjunctival blepharoplasty
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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.
Fig. 16 a, b, c, d, e, f Patient C: 58-year-old, before and 0.5 years after midface correction with Aptos Needle 2G
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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 palpe-
bral fossa and nasolabial folds (Figs. 12a, b, 13a, b).
The use of this technique in combination with ble-
pharoplasty, along with the effects that were achieved by
previous methods, made it possible to smooth out groove
Fig. 17 a, b, c, d, e, f Patient E: 46-year-old, before, 1 year and 5 years after midface correction with Aptos Needle 2G
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Fig. 18 a, b, c, d, e, f, g, h Patient H: 39-year-old, before, 1 year, 5 years and 8.5 years after midface correction with Aptos Needle 2G
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Fig. 19 The patient did not like the too prominent bucco-zygomatic areas, so 25 days after Aptos Needle 2G, the threads were removed
Fig. 20 The inflection of one of the Aptos Needle 2G needles was
performed too close to the dermis and caused retraction of the skin,
which was straightened by means of intensive massage
Fig. 21 Aptos Thread 2G threads were inserted too superficially. The
visualization of the threads was eliminated by intensive massage
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under the cheekbone fat, since sutures were fixed to the
periosteum of the orbit margin throughout its entire length
(Figs. 14a–g, 15a–f).
Similar results were achieved by Aptos Needle 2G, but
less invasively, without incisions and only through skin
punctures (Figs. 16a–f, 17a–f, 18a–h).
The nearest postoperative period proceeded smoothly
(Figs. 14b, 15b, e, 24b). The usual phenomenon was
swelling and hypercorrection. Hemorrhages, skin retrac-
tions 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 admin-
istration of resorptive therapy and antibiotics. In rare cases,
it was necessary to remove the threads (Figs. 19, 20, 21,
22, 23, 24a).
Conclusions
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 spe-
cialist, 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.
Fig. 22 Pronounced edema and bruises
Fig. 23 Inflammatory processes after thread lifting
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Compliance with Ethical Standards
Conflict of interest The authors declare that they have no conflicts of
interest to disclose.
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Fig. 24 a, b, c Patient F: 33-year-old, before, right after the implantation of Aptos Thread 2G (there is no retraction of the derma in the
projection of the zygomatic arch, nor in the area of the nasolabial fold) and after 6 months
Aesth Plast Surg
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