Autologous Suspension Threads
The concept of suspending and lifting tissue using suspension threads originated in ancient Egypt, where golden threads were used under the skin to obtain a bit of inflammatory tightening. It is rumored that these gold threads may have been the source of Cleopatra’s beauty.
Late in the 20th century, the use of gold threads resurfaced in Russia, Asia, and Europe. A Russian, Dr. Adamyan, obtained a US patent for a combination gold/polygycol thread combination in 2000, but these were never commercially produced. Sulamanidze, another Russian, pioneered the Aptos thread beginning in 1997. He cut barbs into his own threads before finding a larger scale manufacturer.
Dr. Alcalmo, a surgeon from New Jersey, applied for a US patent in 1956 for the use of barbed threads that might more securely hold sutured tissue together. These were never commercially developed. Dr. Harry Buncke, well known for his microsurgical techniques, developed a “one-way” suture based on sea urchin spine structure, primarily for the purpose of tendon repair and surgical incision closure. He received a patent for this in 1999.
Woffles Wu in Singapore began using Aptos threads, immediately followed by his own version of barbed threads, in 2001. He noted that the threads “cheese-wired” or cut through the soft tissue, and worked on several adaptations to overcome this, including the “X” lift which intertwined the threads. Dr. Nicanor Isse met Dr. Wu and began producing his own threads. After initial success, he noted the lasting value of barbed threads was not strong. He then began working on coned threads, currently marketed under the trade name “Silhouette”.
While the concept of suspension threads is very attractive—subcutaneous placement under local anesthesia with very little down time—each iteration has failed to prove lasting value to the physician and the patient. Three factors contribute to this problem:
- “Cheese-wiring” or cutting through skin or soft tissue by the sutures following placement. All soft tissue can be transected with sutures, especially stiff sutures, due to animation and muscular action in the treatment region.
- Breakage of the suture, especially barbed suture, is not uncommon. There is a weak point at the base of each barb where the suture diameter is quite narrow. With routine facial expressions, direct trauma, or other manipulation of the treated area, tension on the suture can cause it to fail.
- Bunching, wrinkling, or dimpling of the soft tissue and skin is not uncommon when a poor candidate is treated. Lack of duration of effect leading to disappointment in either short-term or long term outcome is the benchmark for the sustainability of new ideas.
Because of the shortcomings of suture based suspension methods, I began in 2009 to research the possibility of using autologous tissue manipulation to create both skin surface area contraction as well as directional molding of superficial soft tissue.
First, the basic cause of “skin” laxity associated with aging needed to be figured out. Simple histology provided no clues as to the aging process of soft tissue. Therefore I decided to look at soft tissue using the scanning electron microscope. People’s skin and the underlying adherent soft tissue act as a unit; perhaps by causing the soft tissue mass to shrink, the overlying skin would follow.
While loss of bone and muscle certainly contribute to the aged appearance of many body parts, the skin itself should not take the blame for a region that has started looking old or pendulous. Perhaps if the underlying structure could be restored as a framework for the skin to rest upon, the improvement could be achieved in a manner similar to that of collagen suspension threads—without cheese wiring, breakage, or lack of a sustained response. The collagen formation response would need to be fractional, in order to keep the soft tissue soft.
My first case using this concept for breast lifting was performed in conjunction with a breast augmentation. Evaluation of the patient before surgery showed that her nipple-areolae were quite low, with very little normal skin appearing from the front view. The oblique view shows that her lower breast rests upon the epigastric skin. I knew that implant placement alone would be a bad idea, as the ptotic tissue and nipple complex would hang below the base of the implant.
Following injection of standard tumescent fluid, a minimally invasive bipolar radiofrequency device was used to thermally heat the superficial fatty layer of the breast prior to subpectoral implant placement. The patient also had an abdominoplasty. This combination of procedures gave an incredibly good result.
Limitations of the procedure include the lack of ability to correct all degrees of pendulous breasts. Only grades I and II ptosis are able to be improved with this scarless, nonexcisional RF based technique. The quality of existing soft tissue, and the patient’s compliance with wearing postoperative support garments can significantly affect and limit final outcome. While some lifting is apparent immediately, most patients see a peak of improvement at 6-12 months.
How long do these results last? Again, it depends on the individual. Some patients see additional improvement without retreatment for up to 2 years. At four years, a small amount of aging is visible, but the appearance does not return back to the pre-op level of laxity by this point.
New techniques are able to provide directional shaping as well as overall skin envelope reduction. By providing focal tightening in areas that are significantly lax, a defined round breast shape can be created. The challenge of reducing nipple-areola diameter remains; this cannot be corrected with the subcutaneous device alone. Research into deep RF needling may provide additional help in superficial skin contraction.
Radiofrequency energy is being used to tighten skin, as well as to mold and directionally shape masses of soft tissue. The ability to focally correct areas of pendulosity using minimally invasive devices may provide a solution to problems that cannot be corrected with surgical excision, such as submental laxity, upper arm laxity, pendulous breasts after breast feeding, and mild periumbilical or suprapubic loose skin following childbirth or weight loss.
©Dr. Diane Duncan, MD.