Neck Reduction Surgery

 Reduction of Neck

Aging of the face and neck results in ptosis of soft tissues and the appearance of more prominent facial lines.1 For correction of these changes, surgeons are increasingly reporting procedures with fewer incisions and shorter postoperative recovery periods. Many of these procedures utilize nonabsorbable sutures in the dermis and subcutis to lift lax skin.^2-10 Limitations of these implants have included the protrusion of sutures through the skin,^2-3 asymmetry of cosmetic effect requiring correction with additional sutures,^3-5 and limited durability of effects.⁴ A new modified polypropylene suture marketed as Contour Threads™ was approved in 2005 by the US FDA for lifting ptotic skin of the face and neck. This implant is supplied as a 25cm polypropylene suture with a barbed middle portion. It is attached to a 7-inch straight needle distally and a 26mm 1/2 circle taper needle proximally.

There are several potential advantages of this new implant. It is designed to tie with a paired suture and be anchored to underlying fascia or periosteum, theoretically reducing the likelihood of migration and loss of cosmetic effect. Similar to the Isse Endo Progressive Face Lift Suture,⁶ and in contrast to the Aptos thread, the barbs along this suture are oriented in only one direction. These unidirectional barbs when combined with more secure anchoring ideally limit and lock motion into one well-controlled vector. This also allows for postoperative correction of asymmetry of tightening. Finally, the suture material is clear, making it difficult to visualize under thin or transparent skin.

Procedure and Technique

Placement of Contour Threads™ to reduce ptosis of the brow, neck, middle and lower face may be performed in an outpatient setting under local anesthesia. The surgeon first establishes the degree and direction of the desired tightening. This determines the course and number of sutures that will be placed. Infiltration of local anesthesia is limited to these lines and the insertion points of the straight needle.

For lifting of the brow, middle, and lower face, 3-4mm incisions for insertion of the straight needle are made posterior to the frontal and temporal hairline. For lifting of the neck, incisions are made posterior to the sternocleidomastoid muscle of the lateral neck. To place an individual thread, the surgeon guides the straight needle through the incision and into the subcutaneous plane. For some anatomic locations, it is advantageous to bend the needle to more easily allow it to follow the curves of the face. The needle is advanced in this plane in a zig-zag movement along the marked trajectory. Once anchored, this zig-zag placement of the suture limits retrograde motion along the suture and results in an implanted suture that is longer than the drawn trajectory. This maximizes the number of barbs in the subcutis and theoretically provides more stability of the translocated skin.

Movement of the needle and suture through the subcutis is generally well tolerated by patients. If the straight needle moves superficially to this plane it is immediately apparent as linear dimpling of the overlying skin. If the needle enters the deep subcutis or approaches the muscle fascia or periosteum, the patient will report the sensation of pain or pressure. At any point, the straight needle may be partially or completely removed and repositioned.

The straight needle exits the skin inferior to the eyebrow or near the medial face or neck. It is cut from the thread after pulling the attached suture through the skin. This leaves the barbed portion of the thread buried in the subcutis with the free ends extending from the proximal insertion point and the distal medial face exit point. The curved needle on the proximal end of the suture may then be used to anchor the suture near its insertion to the underlying fascia or periosteum. A 3-4mm incision, 1-2cm posterior to the insertion points serves as an exit point for the curved needle after deep suturing to the fascia or periosteum. Greater security of this anchor point is achieved by tying this suture at its proximal end with a paired suture running a similar parallel course in the skin. The resulting knot can be seated in this posterior incision by gentle traction on the distal ends of the paired sutures.

When all planned sutures have been placed and anchored, the patient returns to the seated position. Holding the distal end of the suture protruding from the medial face, brow, or neck with one hand, the surgeon uses the other hand to push the lax skin overlying the suture towards the anchoring point. The unidirectional barbs catch on the fibrous septae of the subcutis preventing retrograde movement. Together, the surgeon and patient decide the degree of tightening along any given suture. The distal end of the suture extending from the medial face, brow, or neck is cut at its exit point and retracts under the skin. Incisions used for insertion of the straight needle and anchoring heal rapidly by secondary intention.

Translocation of the skin along the suture causes the lax skin of the face and neck to accumulate at the hairline and lateral neck. The resulting folds of skin are quickly and almost completely remodeled or redistributed to the scalp and neck in several days to weeks, even in older patients with relatively inelastic skin. Mild complications such as swelling, bruising and subjective feelings of "tightness" usually resolve within 1-3 weeks. Transient neuropathy of the greater auricular nerve has occurred in several patients when using the sternocleidomastoid muscle fascia as an anchoring point on the lateral neck. Leaving the knotted proximal ends of the paired sutures unanchored in the subcutis is a cosmetically acceptable alternative in this location. It is not clear if this will reduce the incidence of mononeuropathy or be as stable as an anchoring point, although preliminary results suggest that the incidence of neuropathy drops significantly with this technique modification.

After the resolution of initial postoperative swelling, any subjective discomfort from tightening or perceived asymmetry of tightening may be addressed without inserting more sutures or creating new incisions. Carefully applied firm retrograde pressure along a suture will result in the focal release of several underlying barbs from their attachment to fibrous septae. This release can be appreciated as a subtle clicking sensation under the surgeon's finger. Threads have been successfully released up to 9 weeks postoperatively.

Discussion

Because the Contour Thread™ barbs may be released with intense pressure, patients must initially avoid strenuous exercise or movements that could dislodge the tightened skin from the hundreds of barbs along the sutures. Non-peer reviewed data from the manufacturer demonstrate that in laboratory rats these sutures develop a fibrous capsule that becomes well integrated into the dermis and subcutaneous tissue over several months.11 Theoretically, a similar process in human skin could lead to a secure and long-lasting cosmetic effect. The actual long-term durability of the tightening effects of these sutures is unknown. Early adopters of this procedure have demonstrated maintenance of cosmetic effects at 6 months.¹²

Outcomes with more than 25 patients at our center for up to 12 weeks have been excellent. All but one of these patients have maintained greater than 90% of their initial correction, and all have been satisfied with their results. One of our earliest patients reported a subjective appreciation of a 50% loss of tightening at 11 weeks. This loss of tightening effect may be a result of the fact that early in our experience we used fewer threads on the middle and lower face than we do now.  

Conclusion

The use of barbed sutures appears to be a viable strategy for lifting and repositioning of facial tissue. The recently US FDA approved Contour Threads™ provides advantages to the surgeon and patient that other thread systems do not. However, the early success seen with Contour Thread™ lifts must stand the test of time.
Longer follow-up studies are essential, and final judgments as to the utility of these threads cannot be made in the absence of longer term (i.e., greater than 6 months) data.

The optimal techniques for placement and removal of sutures, the consequences of long-term subdermal polypropylene placement, and the potential for revision and retightening of extant sutures should be the subjects of future investigation.