The Use of Intra-SMAS Absorbable Barbed Sutures to Reinforce a High-Vector Pull during Rhytidectomy

Abstract

Sir: Sometimes, the superficial musculoaponeurotic system (SMAS) is insubstantial and must be folded over a Vicryl (Ethicon, Inc., Somerville, N.J.) mesh1 to resist suspension without tear. Described in this viewpoint is a combination of open face lift with lateral SMASectomy2 and the use of four to six bidirectional absorbable barbed sutures3 that are placed under direct vision in a “weave” intra-SMAS fashion, catching with the barbs both edges of the SMAS and closing a 2.5- to 3.5-cm breach by traction and anchor to the temporal area. The lateral and medial edges of the SMASectomy are perforated with a blunt Coleman cannula and a 12-cm-long, 2-0, absorbable, bidirectional, barbed suture (PromoItalia International, Italy) is placed through the cannula. After grasping the end of the suture distally with a forceps, the needle is withdrawn and a small “pull” is transmitted to the suture to feel the “spiral barbs” impact the SMAS tissue (Fig. 1). A 0.5-cm tip of caudal barbed suture is left and the proximal part is passed through a 22-gauge needle and taken out in the temporal area. We control the pull on the sutures that protrude from the temporal hair by placing the patient in front of a mirror and letting them tell us how much to pull or release.Fig. 1.: (Above) A 3-cm strip of SMAS has been resected (lateral SMASectomy) and a blunt Coleman needle is penetrating the lateral portion of the SMAS. (Center) A barbed suture passed through the needle from cephalic to caudal and is grasped by an Adson forceps. (Below) The barbed suture has secured both edges of the SMASectomy, closing the 3-cm gap. Traction of the SMAS is accomplished with two barbed sutures and the SMAS is gathered with elevation of the corner of the mouth.In this study, absorbable barbed sutures were used to close and advance the lower SMASectomy flap, facilitating its superomedial fixation and the suspension of the platysma, and this effect is transmitted to the neck. In primary face lifts with a weak SMAS, two or three barbed sutures act as a “stick over a crooked tree trunk” and make the structure firmer to pull on to. In secondary face lifts, it was also useful when the SMAS ripped with the sutures. The use of absorbable barbed sutures in plastic surgery is very new; they are made of polydioxanone, a monofilament polymer that hydrolyzes between 8 and 10 months, with a degradation of strength that is inverse to the increase of strength of the healing process of the wound. This delayed absorption could create more healing connective tissue over the barbed spines, and this would theoretically strengthen the SMAS with time. With this premise in mind, SMAS suspension-contraction could eventually lift the face structures continuously over time, carrying the entire subcutaneous cheek mass as a unit. Science has shown that absorbable barbed sutures can increase wound strength in soft tissues,4,5 but it still must be established that its slow period of absorption will be adequate to achieve satisfactory results in face lifts in the long run and also be able to preclude concerns about adverse effects, such as possible migration, extrusion, foreign body reactions, local infection, neuromas, nerve damage, palpable beads, and pain. Creating an internal grid basement with barbed sutures is a stimulating concept for use with the SMAS as a monobloc unit that, when suspended, will lift the entire subcutaneous malar and mandibular mass of the middle face in a vertical direction. Arturo Prado, M.D. Patricio Andrades, M.D. Patricio Fuentes, M.D. Alex Eulufi, M.D. Alvaro Cuadra, M.D. School of Medicine Postgraduate School Plastic Surgery Clinical Hospital J. J. Aguirre University of Chile Santiago, Chile DISCLOSURE None of the authors has any financial interests to declare or any relation to the manufacturer of absorbable barbed sutures.