APTOS Suture LiftingMethods : 10 Yearsof Experience

Marlen Sulamanidze, MDa,b, Georgii Sulamanidze, MDb,*

KEYWORDS� Aptos thread method � Aptos needle method� Aptos spring method

The process of facial aging is manifested asuneven ptosis of the skin and subcutaneoustissues located above and lateral to the nasolabialfold and the superciliary, buccal, mental, and sub-mental areas.

For various reasons, gravitational sagging ofsoft tissue occurs, with the resulting appearanceof overhanging eyebrows, lachrymal grooves,deepening nasolabial folds, and the beginning ofmarionette lines, followed by aggravation andptosis of the angle of the mouth and mental areasbecoming more pronounced (‘‘hanging lips’’).

For a long time these deformities were correctedonly by radical interventions: cutaneous, superfi-cial musculoaponeurotic system (SMAS), andperiosteal and subperiosteal face lift.1–4

In any face lift technique, the medial portions ofthe face uncrumple incompletely. Fig. 1 showsthat to the edge of the mobilized skin–cutaneousflap a mechanical force is applied and it isextended to the maximum, with each of themarked, initially 3-cm long portions having elon-gated to a different degree. The farther the portionis away from the point of force application, the lessit extends.

Understanding the cause of this factor, wedecided to develop a method of tissue extensionin which the flap extends evenly along the wholelength. Knowledge of the topographic anatomyand clinical experience persuaded us that onseparate portions of the face the layers of soft

Financial Disclosure: Dr. Marlen Sulamanidze and Dr. Gea Department of Plastic and Reconstructive Surgery, CRussian Federation Health Ministry, Tbilisi, Georgiab Limited Liability Company APTOS, V. Orbeliani str 18,* Corresponding author. V. Orbeliani str 18, 0105, TbilisiE-mail address: gracia@aptos.ru (G. Sulamanidze).

Clin Plastic Surg 36 (2009) 281–306doi:10.1016/j.cps.2008.12.0030094-1298/08/$ – see front matter ª 2009 Elsevier Inc. All

tissues could be easily moved with no mobilizationthereof, with the skin capable of shrinking undercertain conditions.

Barbed threads have long been used in medi-cine to suture tendons and close wound edges;however, operations on lifting facial tissues bymeans of such threads to rejuvenate were firstproposed by us as long ago as 1998 (Fig. 2). Thename Aptos (anti- ptosis), as we called thesethreads, was then given to all products and tech-nologies of minimally invasive lifting, which weredeveloped and implemented in practice.5,6

MATERIALS ANDMETHODS

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Aptos Thread, Aptos Thread 2G, Aptos Nee-dle, Aptos Needle 2G, Aptos Spring: man-ufactured by the CHIRAMAX Ltd. (CzechRepublic), the product possessing a Euro-pean Certificate.

The needle—a guide of the spinal needle typemeasuring 1.1 � 100 mm, manufacturedby the TSK–Supra SIMS Portex Ltd.

Patients: a total of 4580 people; of these, 4388women and 192 men operated on in ourclinic by the same surgical team betweenJanuary 1988 and December 2007. Thepatients’ ages varied from 31 to 77 years.The age- and sex-related distribution isshown in Table 1.

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Fig.1. Experiment that shows different expansions of mobilized cellulocutaneous layer areas through applicationof mechanical force.

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Aptos Thread Method

We performed the first experiments using threadsthat were provided with barbs directed unilaterallyand fixed to a long needle. Through a small inci-sion in the temporal area, we pulled severalthreads subcutaneously. After the lower threadand needle emerged to the surface of the skin,the remainder of each lower thread was cut off,and, after moderate pulling, the upper threadwas sutured to the fascia of the temporal muscle.The same technique was used to pull the soft

Fig. 2. (A–C) Diagrams from patents.

tissues of the submaxillary and cervical regionswith fixation of the upper end of the thread to theperiosteum of the mastoid process (Fig. 3).

Later in 1998, we improved this techniqueslightly by devising a needleless thread withconverging barbs, which was introduced underthe skin by means of a guiding needle, whichmade it possible to abandon incisions (Fig. 4).Such a thread introduced subcutaneously is fixedin soft tissues because of the barbs convergingtoward the middle thereof, carrying subcutaneousfat, pulling it together and distributing it evenly

Table1Age- and sex-related distribution of patients who underwent Aptos suture lifts betweenJanuary1988and December 2007

Number (%) of Patients in Each Age Group

Gender 31^40 years old 41^50 years old 51^60 years old R61 Total

Female 115 (26.1) 167 (37.9) 114 (25.9) 44 (10) 440

Male 3 (7.7) 29 (74.35) 7 (17.9) 0 39

Total 118 (26.5) 196 (40.9) 121 (25.2) 44 (9.2) 479

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along the whole length, thus creating the effect oflifting or obtaining a high contour of soft tissues.

Initially, we used this technique on virtually allportions of the face and neck. During long-termpractice, however, we concluded that the appro-priate use of this method was only for creation ofa high contour of the midface soft tissues and lift-ing of the mental area. Accordingly, we developedan optimal marking of the skin, taking into consid-eration anatomic and functional peculiarities of theportion concerned and the pathogenesis of thedeformity involved (Fig. 5).

We managed to obtain better outcomes in 35- to50-year-old patients who had clear, not very thickskin, with no pronounced atrophy of subcutaneous

Fig. 3. Our first experiment in Aptos lifting.

fat and moderate manifestations of soft tissueptosis (no sharply pronounced nasolabial folds,overhanging of soft tissue bolsters above them,mild distortions of the suborbital contours in theform of lachrymal grooves, and the presence ofhanging lips), who for various reasons refusedclassic face lift operations. Mainly, these were thepatients who wished mild lifting barely visible toother people. These were also patients who hadpreviously undergone cutaneous rhytidoplastyand were not satisfied with the outcome obtainedbecause the facial lifting had been poorlypronounced in the midface portions and highvolume of the buccozygomatic regions was notattained.

Fig. 4. Aptos thread and guide needle.

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Surgical Procedure

To lift the mental regions, the threads were im-planted parallel to the mandibular edge with slightarch-like sagging within the area of the hanging lip.Doing so, we simultaneously solved the problem oflifting and redistribution of the skin and subcuta-neous fat of the hanging lips. The depth of thethread’s implantation varied depending on thethickness of the skin, fat, and the degree of involu-tional alterations, but obligatorily within fattytissue, which is thicker closer to the skin.

The main task we accomplished while lifting themidface area was to create a new high contour ofthe buccozygomatic region by elevation of theptosed soft tissues situated between the nasola-bial fold and lachrymal groove. Movement of thecheek upward and slightly laterally obtaineda more smoothed-out nasolabial fold and lach-rymal groove.

This effect was achieved by placing the threadswithin subcutaneous fat in the form of compara-tively steep arches followed by straighteningthem by pulling the ends and accordingly evenclosing together of soft tissues along the lengthof the threads toward the middle thereof. Theeffect was even more enhanced because withinthe middle part the threads passed relatively

Fig. 5. Method for marking of Aptos thread.

deep, catching SMAS and together with it elevatedfatty tissues from the depth toward the surface.

While gaining experience, we planned ways offurther developing thread-mediated lifting, withthe goals of simplifying the operational technique,enhancing the power of lifting, achieving long-standing results that would persist over time, anddecreasing the risk for complications and undesir-able effects.

Aptos Thread 2G Method

In 2002, we again returned to the idea of usinga single product (ie, a needle with a thread);however, the new suture material was distin-guished by the presence of two needles to theends of which were attached one thread providedwith converging barbs—Aptos Thread 2G(Fig. 6A). This appliance made it possible toincrease the thread’s arm of force twofold, andthus to obtain the power and stability of the lifting.An important novelty herein was that these threadswere coupled by temporary soldering so that inthis position their pointed tips constituted a singlewhole (Fig. 6B). Implementation of the idea of thecoupled needles and a novel technique of theoperation made it possible to place the threadswith no cutaneous incisions through a puncture,obtaining no skin in-drawings in the place of thethread’s bend: both needles were stuck into theskin with the common tip, to be detached underthe skin at the required depth and only there-after advanced in the opposite directions. (accessvideo on Aptos Thread 2G for the eyebrowin the online version of this article at: http://www.plasticsurgery.theclinics.com/)

The Aptos Thread 2G method yielded betterresults during operations of lifting the tail of theeyebrow and mental sagging and more moderateresults in the midface area. Optimal marking ofthe skin is shown in (Fig. 7).

The indications for the middle and lower facialzone were the same as those for application ofthe Aptos Thread method, but with morepronounced pathology. In the midface zone, wetended not so much to create a high volume asto distribute soft tissues upward and laterally.The Aptos Thread 2G was also applied when thepatient wished a more radical and lasting liftingthan the Aptos Thread.

In the area of the eyebrow, Aptos Thread 2Gwas used in cases of moderate ptosis of the lateralportions of the eyebrows, overhanging soft tissuesof these portions above the upper eyelids, roundshape of the eyebrow, and when it was requiredto remove signs of ‘‘watering’’ eyes.

Fig. 6. (A) Diagram of Aptos Thread 2G. (B) Aptos Thread 2G.

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Surgical Procedure

To lift the lateral portion of the eyebrow, thecoupled needles were inserted into the skin ofthe temporal region to the fascia of the temporalmuscle, to be detached herein and pulled apart.One of them was advanced to a greater depth tocatch the fascia and returned back to the subcuta-neous space. Then the threaded needles werealternately advanced along the marked contourto emerge in the marked points, evenly pullingthe thread from the both sides, achieving therequired shape of the eyebrow, with certain hyper-correction. Doing so, the bend of the thread in theplace of entry of the coupled needles wassubmerged under the skin, tightly holding ontothe temporal muscle fascia.

The 2G threads were implanted in the midfaceand mental regions according to the presentedmarking and the same guidelines that weredescribed in the section concerning the operativeprocedure according to the Aptos Thread method.The differences concern the moment of insertion

Fig. 7. Marking of Aptos Thread 2G.

of the needles under the skin: it is important toinsert the needles into subcutaneous fat in thearea of the zygomatic arch, to separate them thereand to pull them apart so as to encompass thefascial bands (reference points) with the place ofbending of the thread and only thereafter alter-nately pass the threaded needles according tothe marking. The same guidelines are given whilelifting the mental area, only the bend of the threadshould catch on the fascia of the parotid salivarygland.

Aptos Needle Method

While gaining experience, we noted that somerejuvenating and lifting operations requiredsuturing through soft tissues in the form of a loopor purse (ie, return of the thread back to the placeof entry to apply the fixing knot), with the threadhaving to be smooth so that tissues could slidealong it.6,7

The next stage of our pioneering thereforebecame the creation of a double-pointed needlewith a smooth suturing thread attached to it in themiddle, the Aptos Needle. (access video on usualneedle versus Aptos Needle in the online versionof this article at: http://www.plasticsurgery.theclinics.com/) Such a needle is capable of beingpassed bidirectionally, which allows for it to bepassed under the skin along a polygonal or elon-gated contour, also providing subcutaneoussuturing through the soft tissues without dimplingof the skin and obtaining an even lifted contour.

With the help of different Aptos Needle modifi-cations (Fig. 8), we worked out minimally invasiveaesthetic operations for sewing through softtissues of the midface, the submaxillary andcervical zones (2003), the chin, elongated and dis-tended lobes of the ear, and ptosed mammarygland (2004).

Sewing Through and Lifting of the Midface

This technique may be used independently and ina combination with the classic or transconjunctival

Fig. 8. Different modifications of the Aptos Needle.

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blepharoplasty (Fig. 9). (access video on APTOSNeedle-midface in the online version of this articleat: http://www.plasticsurgery.theclinics.com/)

In the first instance, the operation commencedfrom making a 2- to 3-mm cutaneous incisionalong the lower crow’s-foot line, advancing thescalpel’s blade to the osseous edge of the eyesocket (Fig. 9, point 1). This approach was usedto introduce the tip of the Aptos Needle 4/0 (fromeither side) so that it could entrap the periosteum.Then the needle was advanced to point 2 near thebase of the wing of the nostril. Here it was carefullybrought from under the skin, but not completely,with the second needle’s tip remaining within fattytissues at a depth of 0.5 to 1.0 cm, followed byrotating the Aptos Needle by 90� and then thesecond needle’s tip being advanced towardpoint 3. Here the needle was also brought to thesurface with incomplete exit. Then the needlewas rotated 90�, returned to the site of the incision,and brought to the surface through the wound.Here both ends of the thread were pulled andtied by several knots.

Fig. 9. Marking of midface lifting by the Aptos Needle me

The second and third sutures were applied in thesimilar manner according to the marking. Taken alltogether they had various direction vectors andcreated a new, elevated, aesthetically more favor-able contour of soft tissues, with smooth transitionto the neighboring regions.

For an operation performed through the classicor transconjunctival approach, after isolation andexcision of fatty hernias in the amount required,soft tissues of the midface were sutured throughso that the knots were distributed along the perim-eter of the lower osseous edge of the orbit, arcusmarginalis (Fig. 9).

To sew through and lift the submaxillary andcervical areas, we made incisions up to 1 cm longfrom both sides and the retro-aural regions in theprojection of the processus mastoideus to the peri-osteum onto which we applied holding sutures(Prolene 2/0) (Fig. 10). (access video on APTOSNeedle-neck in the online version of this articleat: http://www.plasticsurgery.theclinics.com/)

The Aptos Needle 2/0 was inserted through oneof the incisions, then advanced subcutaneouslyalong the projection of the lower line of the markingfor as long as the length of the thread permitted(usually 15 cm). Here it was brought to surface ofthe skin and pulled out, but not completely.When the second tip remained under the skin ata depth of approximately 0.5 cm, the needle wasturned and the second tip was used to continuepassing the thread farther according to themarking. Usually it was necessary to again bringthe needle to the surface nearer the angle of themandible on the opposite side, turn the needle,and continue advancing it again with the first tipuntil it appeared in the wound contralaterally.

thod.

Fig.10. Marking of neck lifting by the Aptos Needle method.

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Here the needle was completely brought to thesurface, with the thread pulled out as far as itwould go, after having its end preliminarily tied tothe holding threads from the first side. At this pointthe thread was tied to the holding threads on thisside.

We performed the same passages of thethreaded needle first along the upper and thenalong the middle lines of the marking, each timetying up to the holding threads on both sides.

Three threads were thus advanced under theskin of the submaxillary region without dimplingof the skin and with anchoring of the ends of thethreads to the periosteum of the mastoidprocesses, like a hammock lifting and supportingsoft tissues in a new position, improving thecontour of the entire submaxillary and cervicalregions. (access videos on Aptos Needle-chin andAptos Needle-breast in the online version of thisarticle at: http://www.plasticsurgery.theclinics.com/)

Aptos Needle 2G Method

Our latest development is experimental so far—the suturing material and Aptos Needle 2Gmethod.8 (access video on Aptos Needle 2G inthe online version of this article at: http://www.plasticsurgery.theclinics.com/)

This new product unites the capabilities of AptosThread 2G and the Aptos Needle. The Aptos Nee-dle 2G and the Aptos Thread 2G make up onethread with variously directed barbs convergingtoward the middle and two needles. These

needles are double-pointed and the thread isconnected to them in the middle portion, as inthe Aptos Needle (Fig. 11). Like the needlesof the Aptos Thread 2G, the tips of the needlesof the Aptos Needle 2G are fastened together onone side with temporal soldering, constituting inthis position a single tip. This design makes itpossible to insert both needles under the skinthrough one puncture and to separate them atthe required depth. Owing to the original idea ofcoupling two needles, the operations can bedone without incision or dimpling of the skin.

The operative procedure using the Aptos Needle2G method is not more difficult than manipulationswith the Aptos Thread 2G, but lifting of soft tissuesherein is more powerful and stable at the expenseof subcutaneous turns of the needle andadvancing the barbed thread along the contourof the ‘‘pouch’’ or a hook without disturbing theintegrity of bulges and dimpling of the skin. Weused the product and technique of the operationAptos Needle 2G on virtually all portions of theface to move tissues and to create high contours;however, so far we can recommend it for wideapplication only in lifting of the midface zone(Fig. 12).

The operation was performed approximately inthe same manner as the Aptos Thread 2G tech-nique: the twin needle was inserted into the areaof the zygomatic arch, to be separated in thesubcutaneous fat at a depth of approximately1 cm around the portion of the fascial bands,and the thread was advanced farther on each nee-dle according to the marking. After exiting and

Fig.13. Aptos Springs.

Fig.11. Aptos Needle 2G.

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incomplete surfacing of the needles from underthe skin they were turned within subcutaneousfat (as with the usual Aptos Needle) and alonga new contour returned back to the area of thezygomatic arch, where after moderate pulling thethreads were cut and the ends submerged underthe derma.

Aptos Spring Method

Involutive alterations in the kinetically active zones(marionette lines, ptosis of the angles of the mouth)were removed by the elastic lifting with specialthreads9 we devised in 2003. This is a heliciformthread made according to a special technologyfrom special shape-memory POLYPROPYLENE(Fig. 13). (access video on Aptos Spring in

Fig. 12. Marking of lifting by the Aptos Needle 2Gmethod.

the online version of this article at: http://www.plasticsurgery.theclinics.com/)

Operational Technique

To lift marionette lines, it is necessary to implanttwo Aptos Spring threads on each side perpendic-ular to the wrinkle itself (Fig. 14). Because thespring needle is coiled onto an aspirating needleand is thus in a compressed state, before beingapplied it was freed from fixation on the side ofthe base and spread along the needle’s length.In this working condition of the spring, the needlewas inserted in the area of the zygomatic arch,advanced subcutaneously according to themarking, and surfaced approximately 1 cm afterpassing of the tip of the wrinkle’s projection.Then the thread was released from fixation fromthe side of the tip, with the surgeon slightly pullingthe ends of the spring and cutting off the extra

Fig. 14. Marking of lifting by the Aptos Springsmethod.

APTOS Suture Lifting Methods: 10 Years Experience 289

length, submerging the ends under the skin. Otherthreads were placed in a similar manner.

To lift the angles of the mouth, the upper threadwas implanted in a somewhat different manner tothe angle of the mouth and farther along theprojection of the vermilion border of the upper lipby approximately 1 to 1.5 cm. Doing so made itpossible to slightly invert the lateral edge of theupper lip to somehow increase its volume and toattain an alteration in the direction of the angle ofthe mouth upwards.

RESULTS AND DISCUSSION

Of the 4580 patients, 2133 underwent the manipu-lation as an independent operation. In the rest itwas done in combination with other operationsand procedures, including undercutting of wrin-kles and folds (Aptos Wire method), autolifting,liposuction of mental, submaxillary, and cervicalregions, facial skin peeling, blepharoplasty, facelift, platysmaplasty (Fig. 15), and others. Figs.16–20 show patients who underwent simultaneousoperations.

In most cases we used infiltration anesthesiaconsisting of 1% lidocaine solution with epineph-rine; the solution was injected while the threadswere placed, with an average of 0.3 to 0.5 mL ofthe solution used for one thread. Anestheticswere used in greater amounts only during theoperation of lifting the submaxillary and cervicalareas by the Aptos Needle method. In that proce-dure the percentage of the anesthetic wasdecreased to 0.5 or 0.25.

Fig.15. For 2133 of the 4580 patients, the manipulation wawas done in a combination with one or more classic meth

Among our patients, we observed age-relatedptosis of the involutional pattern more often andsaw acquired ptosis resulting from disease oriatrogenic causes less frequently (a total of 38patients). We saw congenital ptosis in separatecases (11 patients).

Typically, operations using the Aptos methodsproceeded easily and quickly, with the injury in-flicted to tissues being minimal and the outcomeof the intervention seen as early as on the opera-tive table.

The Aptos methods are especially effective inthe midface zone: the nasolabial fold becomes un-crumpled, the lachrymal fold is smoothed out, andthe soft tissues are elevated and moved upwardand laterally, thus creating an integral, even roundcontour of the buccozygomatic area. Based onfollow-up of patients over several years, we notedpreservation of good outcomes from 1 year andmore in most, with the best effect being achievedafter implantation of the threads Aptos Needleand Aptos Needle 2G (Figs. 21–25). Completerelapses of the deformity in the region concernedwere observed only in sporadic cases.

In the area of the tail of the eyebrow (AptosThread 2G), we obtained pronounced liftingupward and laterally, and moderate spreading ofthe upper eyelid skin, especially in the lateralportion. Immediately after surgery, extra lifting ofthe eyebrow and goffered skin in the area of thetemple was considered justified, because withinthe first 2 to 3 weeks during the period of stabiliza-tion of the clinical result, skin adaptation and slightlowering of the brow occurred. We were satisfied if

s performed as an independent operation. In the rest itods.

Fig.16. (A, D) A 52-year-old patient is shown before surgery. (B, E) The patient is shown 3 days after surgery con-sisting of upper and lower classic blepharoplasty, stitching of the midface by Aptos Needle, lifting of the mentalarea by Aptos Thread 2G, liposuction of the submaxillary and cervical area, and Aptos Needle stitching. (C, F) Thesame patient is shown 1 year after surgery.

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the good outcome obtained persisted for 8 to 12months (Figs. 26–29).

In the mental area (methods Aptos Thread andAptos Thread 2G), depending on the degree ofptosis and skin excess after the operation, we

observed more or less pronounced lifting ofhanging lips and skin redistribution upward andlaterally. We noted wrinkled skin in the immediatepostoperative period on the background ofpronounced improvement of the oval of the face.

Fig.16. (continued).

Fig.17. A 48-year-old patient is shown before (A), 10 days after (B), and 11 months after (C) surgery consisting ofupper and lower classic blepharoplasty, stitching of the midface by Aptos Needle, liposuction of the submaxillaryand cervical area, and Aptos Needle stitching.

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Fig. 18. (A, C, E) A 37-year-old patient is shown before surgery. (B, D, F) The same patient is shown 2 years and7 months after face autolipofilling, and midface and mental area lifting by Aptos Thread.

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In most cases, we noted persistent results up to1 year (Figs. 30, 31).

During the last years for minimally invasivecorrection of deformities of the submaxillary andcervical area, we have been using only the AptosNeedle method. In doing so, we attained moderateredistribution of the ptosed skin from the middlelaterally and obtained a sufficiently good profile.We observed no complete relapse of the deformityeven after 3 to 4 years. Certain weakening of the

threads and sagging of soft tissues (after 1–3 years)were, if necessary, easily corrected by lifting fromone of the ends of the knot and anchoring it ina higher position (Figs. 32–34).

The success factors for obtaining goodoutcomes while using the Aptos methods of rigidfixation are as follows:

Use only when indicated and correctly selectthe method.

Fig.19. (A, C) A 45-year-old patient is shown before surgery. (B, D) The patient is shown 2 years and 8 months afterupper and lower classic blepharoplasty, stitching of the midface by Aptos Needle, liposuction of the submaxillaryand cervical area, Aptos Needle stitching, marionette lines lifting by Aptos Springs, and browlift by Aptos Thread2G.

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Determine the purpose of the operation (ie,what effect is expected from the implan-tation of the threads) lifting of tissues,their redistribution, creation of a newhigh volume, or a combination of theseeffects.

Place the threads in areas where they cannotcounteract the kinetics of facial musclesand where you can easily remove layers

of soft tissues unimpeded without opera-tive dissection thereof.

Observe the depth for placing the threads de-pending on the purposes of the operation,the condition of the skin, and the portion ofthe face.

Place the threads such that the barbs fromeach side of the thread are equal bothquantitatively and by strength (this condi-tion concerns only Aptos Thread).

Fig. 20. A 53-year-old patient is shown before (A) and 17 months after (B) midface lifting by Aptos Thread.

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All the above-described types of thread-mediatedlifting are rigid. On the areas of the face that areespecially active (for example, mimic, masticatory,and other muscles in the perioral area), lifting withbarbed threads or by the Aptos Needle method isunsuitable because constant tissue movementrapidly destroys the result. For correction of involu-tive alterations in the perioral area we thereforeused the Aptos Spring method.

In virtually all cases, this technique allowedremoval of labiosubmaxillary wrinkles andprovided nonrigid, elastic lifting of the angles ofthe mouth in the immediate and remote

Fig. 21. (A, C) A 36-year-old patient of is shown before surlifting by Aptos Thread.

postoperative periods. Polypropylene springsplaced in subcutaneous fat in the distended formcontract and delicately entail the soft tissues.They contract and extend synchronously with themuscles during the mimic and masticatory move-ments. Several months after, the threads arecovered with fibrous tissue, which later enhancesand stabilizes the effect. With the exception ofseveral cases of a rapid relapse of the deformity,when the contracting springs were not fixed intissues but slipped into the needle-createdchannel, we observed a stable outcome within1 to 2 years (Figs. 35–38).

gery. (B, D) The patient is shown 2 years after midface

Fig. 22. A 54-year-old patient is shown before surgery (upper left). The same patient is shown 5 days after midfacestitching by Aptos Needle (lower left), 18 months later (upper right), and 3 years and 6 months later (lower right).

Fig. 23. A 29-year-old patient is shown before (A) and 3 years and 3 months after (B) midface stitching by AptosNeedle through a transconjunctival blepharoplasty approach.

Fig. 24. A 37-year-old patient is shown before (A) and 11 months after (B) midface Aptos Thread 2G.

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Fig. 25. A 35-year-old patient is shown before (A) and 13 months after (B) midface lift by Aptos Thread 2G.

Fig. 26. A 53-year-old patient is shown before (A) and 17 months after (B) browlift by Aptos Thread 2G.

Fig. 27. (A, C) A 46-year-old patient is shown before surgery. (B, D) The patient is shown 15 months after browliftby Aptos Thread 2G.

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Fig. 28. A 40-year-old patient is shown before (A), 3 days after (B), and 11 months after (C) brow-tail lift by AptosThread 2G.

Fig. 29. (A) A 67-year-old patient is shown after transection of the rami temporales nervi facialis face lift. She ispictured before surgery. (B) The same patient is shown 8 months after left-side browlift by Aptos Thread 2G.

Fig. 30. A 44-year-old patient is shown before (A) and 1 year after (B) lifting of the mental area by Aptos Thread2G.

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Fig. 31. A 38-year-oldpatient is shownbefore (A) and5months after (B) liftingofmentalareabyAptosThreadmethod.

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Complications and Undesirable Events

While performing any aesthetic operation or mini-mally invasive manipulation on the face one canencounter complications, such as inflammatoryprocesses up to suppuration; disturbed integrityof the parotid salivary gland, little branches of thefacial nerve or large vessels; and hematomas.The Aptos methods are not guaranteed againstsuch complications.10–12 Such complications arenot intrinsic to the nature of the method itself.Prevention of the mentioned complicationsconsists of observing the principles of the regionalanatomy of the face and its peculiarities, usingasepsis and antiseptics, delicately performing anintervention, and treatment, including antibacterialtherapy, general surgical intervention, and specialintervention (microsurgical, physiotherapeutic,and others) (Figs. 39, 40).

Characteristic of the methods of thread-medi-ated lifting and side effects are as follows:

Fig. 3cervi

For the Aptos Thread method: disruption ofthe threads as a consequence of unilateralslackening of the barbs, surfacing of the

2. A 46-year-old patient is shown before (A) and 15 mocal areas by Aptos Needle.

threads, their migration, a short in time(up to 3 months) and unstable result.

For all Aptos methods: asymmetry, hypercor-rection, visualization of the threads, linearhemorrhages along the length of the thread,hematomas, and dimpling of the skin in thesite of needle punctures (Figs. 41–46).

Prevention of the mentioned complications, sideeffects, and undesirable events consists ofknowing the pathogenesis of ageing and ptosisof the facial soft tissues, correct understandingof the essence of lifting by the Aptos methodsand selecting the proper method, faultlesshandling of the technique, and delicate perfor-mance of the intervention. Treatment is associatedwith removal of the slackened and migratingthreads, repeat thread-mediated or classic lifting,physiotherapy, and massage.

For thread removal in our clinic we use themethods of noninvasive detection of threadsunder the skin (ultrasonography, visualization bymeans of bright directed light) and minimally inva-sive removal thereof by means of a special needle.

nths after (B) stitching of the submaxillary and

Fig. 33. A 55-year-old patient is shown before (A), 4 days after (B), and 18 months after (C) stitching of thesubmaxillary and cervical areas by Aptos Needle.

APTOS Suture Lifting Methods: 10 Years Experience 299

With experience, this manipulation presents nodifficulty for the operator (Fig. 47).

Complications and unfavorable events are sorare and inconsiderable that specialists inaesthetic surgery and cosmetology should not

Fig. 34. A 35-year-old patient is shown before (A) and 1cervical areas with the Aptos Needle.

abandon the methods of thread-mediated liftingfor this reason.

As we have gained experience in using the Ap-tos methods, we have been constantly improvingthem, enhancing the power of lifting, the safety

5 months after (B) stitching of the submaxillary and

Fig. 35. A 43-year-old patient is shown before (A) and directly after (B) marionette line lifting using the AptosSpring.

Fig. 36. A 35-year-old patient with right-side phlegmon of the upper jaw is shown before (A) and 3 months after(B) right-side lifting of the angle of the mouth using the Aptos Spring.

Fig. 37. A 60-year-old patient is shown before (A) and 20 months after (B) marionette line lifting using the AptosSpring.

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Fig. 38. A 46-year-old patient is shown before (A) and 4 months after (B) marionette line lifting using the AptosSpring and midface lifting with Aptos Thread.

Fig. 39. Two days after implantation of Aptos Thread, this patient had hematoma of the mental and buccal areas.

Fig. 40. (A) Ten days after implantation of Aptos Thread 2G, the patient had suppuration of the thread insertionsite. (B) The moment of thread removal is shown.

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Fig. 41. This patient had thread migration 4 monthsafter implantation of Aptos Thread.

Fig. 43. Superficial arrangement of thread under themucous membrane was seen in this patient 3 monthsafter implantation of Aptos Springs.

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of the operation, and the durability and stability ofthe results.

We have experienced all things characteristic ofimplementing any novel technologies: initial admira-tion and euphoria, disappointments, complications,and cautious attitude. Because of these circum-stances and because doctors of our clinic are thedesigners of the Aptos methods we can expressour opinion concerning thread-mediated liftingmethods suggested by other authors.

Many doctors have still been placing barbedthreads using an outdated technique that requiresincisions and visualization of solid structures (forexample, temporal fascia) to which threads aresewn. With the advent of coupled needlesprovided with threads and the respective tech-nology (methods using Aptos Thread 2G and

Fig. 42. This patient had asymmetry 1 week afterimplantation of Aptos Thread.

Aptos Needle 2G), there is no need for skin inci-sions, and the operations are thus considerablysimplified with no damage for the future result(Fig. 48).13

We doubt the efficacy of using long barbedthreads for lifting and rigid fixation of the kineticallyactive zones of the face and neck, and the feasi-bility of their use without taking into considerationthe anatomic peculiarities of various facial regions(Fig. 48B). The authors of this methodology do notexplain, for instance, what happens to the threads’barbs directed from the temporal or even breg-matic areas through the entire cheek downwardto the submaxillary region, when a person widelyopens his or her mouth. Also unclear is whathappens to threads that have been advancedfrom the temporal area downward to the upperlip (the nasolabial triangle), to the labiomentalfold (marionette line) when the patient produces

Fig. 44. Superficial arrangement of thread under theskin was seen in this patient 2.5 months after implan-tation of Aptos Thread.

Fig. 46. The patient is shown 2 weeks after lowerblepharoplasty and midface stitching by the AptosNeedle. One of the stitches is sewed to the edge ofthe eyelid, not to the periosteum of the arcusmarginalis.

Fig. 47. Furrier needle for removing threads.

Fig. 45. This patient had an allergic reaction 2 daysafter implantation of Aptos Thread.

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Fig. 48. Faulty methods of soft tissue lifting by threads with protrusions. (A, B) Wrong marking. (C, D) Such liftingis possible only in combination with Botox injections.

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mimic movements of the lips and the entire perio-ral area. Procedures placing threads from the ret-roaural area to the submental and cervical regionsin the form of a fan also usually prove to be ineffec-tive (Fig. 48B).14

We also do not recommend following theadvice of those colleagues who lift the wholeeyebrow and even the forehead by thread-medi-ated methods.15 Doing so, they do not take intoconsideration the presence of the powerfulfrontal muscle and its kinetics, which rapidlydestroy the barbs of the threads, leading toa relapse of the deformity (Fig. 48C). In this situ-ation it seems appropriate to study the possi-bility of simultaneously using the Aptos Needle2G method and Botox.

During endoscopic face lift procedures forsewing through the ptosed tissues, manysurgeons use suture material that is inconvenientfor this purpose and that leaves dimpling on theskin. The Aptos Needle is the best methodpossible for these purposes.16–20

Sixteen patients who wished a better radicaleffect and were dissatisfied were subjected toface lift at various times following the first threadlifting (0.5–2 years). Intraoperative findings showedthat the implanted threads were in those siteswhere they had been placed. Neither their colornor their structure was altered, and their removalrequired considerable effort because of powerfulcoherence of the barbs with the tissues. Histologyrevealed that within tissues, the Aptos Threads

Fig. 49. Morphologic specimen eventuated by face lift(1 year after implantation of Aptos Thread).

APTOS Suture Lifting Methods: 10 Years Experience 305

were covered with a solid fibrous membrane,which was especially pronounced around thebarbs, which is yet another explanation of thecause of stability and persistence of good clinicalresults (Fig. 49).21,22

SUMMARY

Absolute advantages of using the Aptos technolo-gies while performing lifting are as follows:

Simplicity, easiness, economy of useMinimally invasive nature and low trauma of

the proceduresReliability and sufficient duration of qualitative

liftingPossible combination with other interventions

and a short rehabilitation period

The Aptos methods constitute a new, nontradi-tional trend in aesthetic surgery, requiring furtherstudy and development. Despite the apparentsimplicity, these operations do have their ownnuances, which if taken into consideration andcomplied with provide a good stable outcome.

Unskillful hands and insufficient experiencecould at best yield undesirable results and rapidrelapses and at worst complications. Such practi-tioners would rapidly be disappointed, ascribingfailures to imperfection of the method and speakingagainst it, which is unfortunate. Doing so, theyignore suggestions to undergo a teaching course.These circumstances thwart progress and hamperimprovement not only of the Aptos method but alsoof minimally invasive aesthetic surgery as a whole.To dismiss suture lifting gives no chance to a largenumber of patients who have appropriate indica-tions and the desire to rejuvenate their appearanceto have an alternative to the classic method of liftingand contour plasty of the face.

APPENDIX: SUPPLEMENTARYMATERIAL

Supplementary material can be found, in the onlineversion, at doi:10.1016/j.cps.2008.12.003.

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