Despite improvements made to the quality of permanent suspension threads giving maximal anchorage, medical lifts of the lower face were not always 100% successful.
The “parallel J” technique, far above and beyond other techniques for re-positioning the upper and median thirds of the face (eyebrows and cheekbones) Offered huge improvements, but we could do even better concerning the lower third, marionette lines and jowls! This is now possible using a technique where suspension threads are inserted into the SMAS.
1) The two patient profiles the most difficult to treat.
The difficulties were particularly present in two patient profiles with one or other extreme profile, which were not rare, concerning the superficial fatty areas of the cheeks: all or nothing.
- Very slim patients with practically no subcutaneous jugal fat either for congenital reasons or following prolonged physical exercise or a pathology. Also, by analogy, patients having undergone a cervico-facial lift with a wide subcutaneous undermining.
In this case, there is not sufficient “matter” or connective tissue to enable the suspension thread to anchor itself powerfully enough. - In contrast, on patients with much subcutaneous tissue, which is frequently slack, and is not sufficiently supported by the cogs of the suspension threads. Even if the number of suspension threads inserted is increased, the problem will be solved for a few months but will not resist the passage of time.
2) Potential solutions…
Since the conventional way to insert suspension threads in the subcutaneous plane is either not possible or not effective enough, a change of insertion plane was necessary.
Two options:
- More at surface level, just below the deeper skin layer, to enable the threads to grip it. Tautening of the skin is certainly convincing but with inacceptable creases and hollows and the threat of the threads becoming visible in the short or long term because our integument system becomes thinner over the years. This solution must be avoided. Failure will be systematic.
- The only alternative was insertion of suspension threads into the deeper skin layers, the SMAS. We shall explain this option.
3) Suspension threads and SMAS: a long-ignored solution
For many years, the choice of inserting suspension threads deeper into the SMAS was ignored by physicians.
Why? When the first suspension threads were used around 25 years ago, they were hailed as an alternative to surgical lifts but were philosophically considered as and christened a “soft technique” by their developers as opposed to surgery, being the “hard solution”. Soft because of the speed of the intervention, its low level of trauma, which required no general anaesthetic; a scalpel-free intervention with no deep undermining, scar-free and undergone directly in the practice. They were an attractive promise, but disappointing results only strengthened their perception as a soft result, in no way comparable with that of a real surgical lift.
Thus, it became more difficult to alter this paradigm and the technique using suspension threads took on apparent simplification becoming commercially and stupidly known as “lunchtime lifts”. Thread lifts spiralled downwards from then on.
Solutions, which never convinced me of their efficacy, started to emerge:
1) Resorbable suspension threads, a clever alternative invented by laboratories and supported by three arguments:
- Why use permanent suspension threads if their gripping power lasts no longer than resorbable threads do.
- Why run the risk of defects when using permanent threads when the results of badly inserted resorbable threads disappear within a few months of the threads being absorbed.
- Resorbability means patients return to the physician’s practice.
These three arguments were quite simply marketing methods, unacceptable to discerning physicians; the immediate consequence, still rife to-day, was to disparage the threads rather than to encourage doctors and laboratories to continue in their efforts to improve the technique.
2) Suggestions for ultra simplistic techniques and insertion methods aimed at reducing intervention time as far as possible. The most blatant being the use of threads pre-placed in a cannula. But by oversimplifying, efficacy suffers. If a cannula limits the risk of ecchymosis for a novice aesthetics physician, it greatly increases the risk of mispositioning the threads. The path chosen by the practitioner is more difficult to adhere to since a cannula tends to “do its own thing”, preferably to slide into softer tissue, not always the practitioner’s choice, far from it.
4) Suspension threads and SMAS: the effective solution for deep insertion of the threads.
It was becoming urgent to break the deadlock and leave behind this simplicity which was confining the threads to disappointments upon disappointments.
The thinking was that: if thread lifts are to differ from the surgical scalpel, their action must be the same so as to obtain the same results. This action is the support of a precise anatomical plane, the SMAS, superficial musculoaponeurotic system; this is a Musculo-fibrous tissue sheet found beneath the fatty tissue and extending over all the cheek area. Most of the mimetic muscles are joined to it.
SMAS represents the cornerstone of practically all cervico-facial lift techniques. Having more or less undermined it and cut or simply plicated it, the surgeon will be able to reposition and return the fatty and cutaneous planes, which accompany a SMAS lift, to their rightful place. Then, most importantly, fix it securely to ensure that the result lasts as long as possible.
Following this thinking, the next step was obvious. The threads too must reposition the SMAS. In order to do this, they must be inserted as a form of threading, which grips the whole length of the SMAS thus ensuring efficacy and invisibility. Unprecedented efficiency combined with exceptional homogeneity. Whilst up until now the strength of the support was the enemy of discretion, one or other had to be chosen.
5) Suspension threads and SMAS: a solution for all my patients.
Remarkably efficient for treating the lower third of the face, today I practice insertion into the SMAS for all my patients and not only for the two patient profiles cited above.
The interest in terms of efficacy and durability is exceptional and constitutes a major breakthrough for medical suspension thread face lifts.
I hope to see you soon,
Doctor Jean-Paul Foumentèze – Aesthetic Doctor in Nice
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