A) A third elastic thread can be implanted. This is fixed in depth immediately below the nostrils; it then travels along a superficial pathway in order to create a triangle extending about halfway down the lip. If the lip is very long, an appropriate amount of skin is removed from beneath, and to the sides of, the columella, without going beyond the nostrils. The two threads are then implanted. Once the threads have been knotted, the operator decides whether further skin needs to be removed. This procedure does not leave the visible scars that are typical of traditional lip-lifting techniques.
Q) What should the patient do after the procedure?
A) The patient must cleanse the small sutured incisions and apply an antibiotic cream for at least 20 days. Old cosmetics must be avoided, as they may be polluted.
Q) At what age is this procedure performed?
A) It is performed when the patient has a long lip. Naturally, implanting the elastic threads has an efficacious preventive effect; the procedure is therefore particularly indicated for patients whose parents have a long upper lip, in order to prevent this esthetic defect. It is also indicated for those who wish to enhance the size of a thin vermilion border in a natural way, without using fillers.
Q) How do you get the vermilion border to turn upwards correctly?
A) The Jano needle must penetrate 5 mm into the vermilion border; it is then extracted until 5 mm of the tip remains in the muscle tissue. The two-tipped needle then rotates and partially emerges at the extremity of cupid’s bow. Its pathway must always be 5 mm inside the vermilion border. The pathway must be superficial, but the threads must have a good grip on the vermilion border. In this way, the vermilion border turns upwards.
A) It can be performed on noses that have a mobile tip. Noses with very evident bony defects are not suited to this procedure; in such cases, we carry out traditional rhinoplasty. Elastic lifting of the nose can improve the appearance of a high percentage of noses that are deemed to be too long. This economical mini-invasive procedure makes “normal” noses look cute. The elastic thread can also be used to correct noses with an acute nasolabial angle that makes breathing difficult.
Q) When the two ends of the elastic thread are placed under tension, do they have to be pulled hard?
A) Yes. Suspension of the nose-tip has to be “over-corrected”. It must be borne in mind that there may be as much as 7 to 10 ml of anesthetic in the nose. When the anesthesia and the edema subside, the tip of the nose will descend by a few millimeters.
Q) What recommendations are there after the procedure?
A) Before suturing the 2 mm incision, we often insert a hemostatic sponge into the cavity; this serves to maintain the knot in depth. Every day, the patient should apply an anti-streptococcal ointment and a small sticking-plaster to the sutured incision. In the first few days, the ointment should also be applied to the nostrils. A “sling” sticking-plaster to support the nose-tip and a few plasters on the bridge of the nose complete the medication.
Q) If there are alterations of the bridge of the nose, do you use a rhinofiller?
A) Pre-existing alterations of the bridge of the nose are normally attenuated after elastic suspension, and can be corrected by means of a rhinofiller.
Q) What type of rhinofiller?
A) I use non-cohesive cross-linked hyaluronic acid diluted to 40%.
A) First of all, only one entry incision is used in order to create both loops. The small incisions are made with an SM67 microsurgery scalpel, which is more precise than a number 11 blade.
Secondly, pre-tunnelling, which greatly facilitates the passage of the Jano cannula through the fibrous subcutaneous tissues of the buttock, had not yet been adopted. Thirdly, the elastic thread is soaked several times in dilute iodo-vinylpyrrolidone, and not in much more costly antibiotic solutions. Fourthly, the skin sutures are all absorbable. Finally, the new video publication clearly explains how to rotate the Jano cannula so as to change direction or to follow a curved pathway without shifting towards the surface. Indeed, as the cannula is rotated and the posterior tip becomes anterior, any shift towards the surface will result in a skin introflection, which must be avoided.
Q) Was the elastic gluteoplasty in the video performed under local anesthesia?
A) Yes. Sometimes, we administer 10 drops of benzodiazepine to keep the patient calm. We carry out anesthetist-assisted local anesthesia only on request.
Q) Is there any risk of infection?
A) There are always risks in this region. You have to disinfect the operating field thoroughly with iodo-vinylpyrrolidone and to prescribe antibiotic therapy, starting on the evening before the procedure. In addition, a mupirocin-based antibiotic ointment must be applied to all the incisions for a few weeks.
Finally, the patient must scrupulously maintain local hygiene by using specific products. She should also take a few days off work; going to work the day after the procedure will increase the risk of infection.
Q) What needs to be done if there is an infection?
A) Infection is very rare. However, if it does arise, you have to follow the protocols on soft tissue infections. This normally means using two antibiotics: one for Gram-positive and one for Gram-negative bacteria. Locally, you can inject dilute teicoplanin or dilute gentamicin plus clindamycin, both with a small amount of lidocaine. If the infection tends to recur, despite antibiotic treatment, it will be necessary to remove the threads through two small incisions.
Q) How do you treat post-operative pain?
A) The pain is subjective. At the end of the procedure, an analgesic can be injected: 1 mL of tramadol + ketorolac tromethamine. If the pain persists the following day, another 1 mL dose can be injected. For the next three days, the patient takes sublingual ketorolac tromethamine. If localised pain is still felt after these three days, intradermal neural therapy is implemented with procaine exactly at the point where the pain is felt. However, this eventuality is rare. We add a small amount of epinephrine to the procaine, to eliminate the vagal effects of this anaesthetic.
In any case, after a few days, the pain of gluteoplasty is tolerable.
A) We normally implant the conizing elastic threads at a depth of ½ cm and the peri-areolar thread at a depth of 1 cm. In this patient, we performed conization at a depth of 1 cm.
We have never had any problems regarding the silicone implant or vascular issues.
Q) Do you also operate on non-drooping breasts that have undergone additive mastoplasty?
A) Yes, we often perform conization in order to eliminate the artificial appearance created by the implant. In this way, the breasts become pointed and the anterior portion is more mobile and natural. After conisation, the areola does not widen and the subareolar tissues do not atrophy.
Q) Is the elastic suspension thread fixed to the subcutaneous tissue of the chest?
A) Yes. The Elasticum EP4 (Korpo, Italy) elastic thread is fixed to the subcutaneous tissue of the chest exactly at the point where the chest skin meets the breast skin. The structure of the subcutaneous tissues of the chest is suitable for suspension, as indeed are the subcutaneous tissues of the breast.
Q) Is the operation painful?
A) Our patients have never complained of feeling pain. Moreover, if the patient wears a supporting bra, the suspension thread is not under tension and causes no discomfort.
Q) Can this innovative Elastic Plastic Surgery procedure also prevent drooping of the breasts?
A) Yes. The new conizing and suspensive “ligaments” prevent stretching of the skin and drooping.
Q) What are the results like?
A) The results of conization are excellent. The breasts look natural and do not seem to have been operated on. The results of lifting are also very good. If the breasts present severe drooping, we have to assess whether the additive mastoplasty was performed properly, and whether the implants were chosen and positioned in accordance with the classic canons of beauty. However, after implantation of the elastic threads, it is still possible to correct the result of an imperfect mastoplasty procedure, if necessary, by moving the areola, so as to obtain a more pleasing result.
A) Many surgeons think it’s impossible to lift the breasts permanently by means of a thread. They are wrong; today, it is possible. To do so, of course, a new surgical thread had to be invented. The Elasticum thread does not cut into the tissues, is impalpable, and, once colonized by connective cells, is transformed into a ligament. We had to decide where to anchor the thread. We excluded the traditionally used sites – i.e. the clavicle and the muscle fasciae – as anchorage at these sites is difficult to perform and always unsatisfactory. The elastic thread is anchored to the subcutaneous tissue of the chest. To do this, we create an ellipse that runs from the most prominent point of the inferior quadrants, surrounds the breast and passes through the subcutaneous tissue of the chest. The elastic thread is implanted through a small incision at the level of the anterior axillary pillar. Naturally, this is not the first procedure in which we anchor the elastic thread to the subcutaneous tissues. Lifting of the upper and lower neck and lifting of the temporal region and eyebrows are further examples. We also carry out conization and suspension of the breasts by means of the elastic thread in surgical mastopexy procedures. In these procedures, we perform only de-epithelialization of the skin, which means that all manipulation of the mammary gland is avoided. Indeed, damage to the mammary tissue inevitably leads to a reduction in breast volume and to the recurrence of drooping because the vascular damage caused. In our procedure, which is exclusively cutaneous, the elastic threads used in conization and suspension yield a long-standing result and improve the upper pole of the breast. If the breasts are asymmetrical, the elastic suspension thread can increase the size of the smaller breast by recruiting a larger amount of skin and subcutaneous thoracic tissue.
Q) If slight introflexion of the skin remains after elastic conization of breasts with implants, what should be done?
A) In order to avoid any introflexion of the skin, the operator should ensure that the pathway of the needle is not too superficial. If any slight introflexions do remain, however, they normally disappear within a few weeks. If they don’t, another elastic thread can be implanted in the apex of the breast; alternatively, they can be corrected by means of Adipofilling. However, permanent introflexions are rare in this procedure.
Q) What can you tell us about the results?
A) Patients are very satisfied; their breasts finally have a natural appearance and the procedure causes little trauma. The areolae are not dilated, and the tissues of the breast apex are preserved. As we know, the elastic thread is impalpable and is particularly suitable for the circular periareolar sutures.
Q) Have there ever been any vascular problems with this elastic encirclement?
A) As the integrity of the tissues is preserved and the incisions are minimal, there are no vascular problems.
A) Elastic MACS and Neck Lifting does not carry the risks of traditional lifting procedures, and can be performed even on heavy smokers. The concept underlying the elastic lifting procedures differs from that of traditional lifting procedures, in which ample dissection of the tissues of the cheeks and neck is carried out; instead of dissecting the tissues, new ligaments are implanted.
As the cheeks and neck are not dissected, the trophic damage caused by dissection is avoided. When the elastic thread and the two -tipped needle (Elasticum, Korpo) are used, the cheeks and neck no longer need to be dissected. Today, it is irrational to think that the face or neck can be rejuvenated by damaging their vascularization. The results of dissection are well known: loss of the subcutaneous tissue and of the natural coloring of the face. In elastic MACS and Neck lifting, the cheeks and neck are placed under traction and suspended by means of elastic threads, which are transformed into ligaments within a short time. Only in the temporal region, below the sideburn, do we carry out a few cm² of dissection, which enables the excess vertical skin to be removed. In comparison with traditional lifting procedures, the scars left by elastic MACS lifting are short, stopping at the tragus.
In the neck, there is no need to remove any skin; the excess skin and subcutaneous tissues cover the new cervicomandibular angle or are repositioned laterally, where they are used to correct hypotrophy of the neck region.
After Elastic MACS lifting, the skin has a more pleasing and more vascularized look; the vessels are no longer stretched by gravitational ptosis and the blood supply to the tissues is improved. The results of Elastic MACS and Neck lifting are extremely natural. With these lifting procedures, the patient does not become more beautiful, but has a more youthful look.
The absence of dissection of the cheeks and neck enables maintenance over time to be carried out easily. Any defects that arise are corrected by means of incisions of a few millimeters. Moreover, the two-tipped needle enables traction to be applied to the tissues exactly where it is needed.
Q) When is basic MACS and Neck Lifting indicated?
A) MACS lifting is carried out if the skin at the sideburn can be folded. For what concerns the neck, simply running the elastic thread between the two fasciae of Loré is indicated in patients who do not have drooping neck skin. The patients seen in this video was a borderline case. If there is drooping skin, Elastic Neck Lifting is performed by means of safety pins. This recent procedure prevents the skin in the anterior neck region from sliding downwards and creating a skin fold. As it is minimally invasive, the basic MACS lift is also indicated in young patients who wish to counteract gravitational ptosis and retard aging.
Q) What are the complications?
A) Immediately after the procedure, the patient may feel some pain, which can be alleviated by specific analgesics. For a few weeks, some skin alterations may remain; these can normally be masked if the hair is long. Particular attention should be paid to the temporal branch of the facial nerve. This nerve is very sensitive and simple traction of the malar region can cause monolateral drooping of the eyebrow. If this happens, we immediately restore symmetry by means of botulin and wait until the nerve resumes its function, as has always been the case. In some cases, we carry out elastic lifting of the eyebrows and neck regions, if this has been planned. This elastic lifting procedure requires no dissection either.
Q) What is Adipolysis used for?
A) Just as Adipofilling enables us to increase tissue volumes where necessary, Adipolysis enables us to reduce tissue volumes (if they are not so large as to require liposuction). We apply this technique of Timedsurgery to reduce a slight double chin, excess volume of the cheeks, and malar pouches. Adipolysis, when performed at the same time as lifting, visibly improves our results. The advantages that Adipolysis has over liposuction are that it does not leave any marks, it causes little trauma, small areas can be treated, it does not cause fibrosis, and it can be repeated after two months, if necessary. Adipolysis reduces the number of adipocytes without damaging the connective stroma. There is no need to apply an elastic bandage to the areas treated. Just one word of warning: the anesthetic solution must not be infiltrated into the areas where Adipolysis is to be performed; rather, barrier anesthesia is carried out.
Q) How have these new techniques of elastic lifting without dissection been received by other aesthetic surgeons?
A) Those who have got to know them, both in Italy and abroad, have adopted them. In Korea, for example, all the most important clinics in Gangnam use the elastic thread. The surgeons who have adopted these procedures operate more and are able to meet the needs of their patients more effectively and more economically; it should be remembered that all the Elastic Plastic Surgery operations are ambulatory procedures. In Italy, a small percentage of surgeons have shown no interest in these techniques, perhaps because it is difficult to imagine lifting the face and neck without ample dissection.
The elastic thread has been designed by a surgeon with great experience of lifting procedures. It does not cut into the tissues and is transformed into a suspension thread. The same surgeon invented the two-tipped needle in 1983. However, after testing the needle with all the threads available at that time, he abandoned its use for several years; all the threads cut into the subcutaneous tissues! Hence, the invention of the elastic thread. This author has never been known to implant an absorbable thread. Moreover, the only non-absorbable thread he has implanted is the Elasticum thread. Indeed, as the son of a professor of Anatomy and Histology, he has profound knowledge of the subcutaneous tissue. He therefore realized that only a new suturing thread could be efficacious, and that a surgical technique that did not damage the trophism of the tissues would revolutionize the surgical lifting of the face, neck, breast and buttocks.
A) For young patients who do not want the skin incisions that MACS lifting requires, or who have little skin to remove. These patients normally want an undemanding procedure that can improve the shape of the face and prevent subsequent drooping of facial volumes.
Q) Can the Elasticum® thread also be used to improve the facial symmetry?
A) If asymmetry is due to gravitational ptosis, it can. In the areas of the face where drooping is most marked, several thread can be implanted. If, however, the asymmetry is due to the lack of adipose tissue, we can correct this by means of Adipofilling®.
Q) Can the knots in the deep temporal fascia ulcerate?
A) All knots can ulcerate through small incisions, especially if the thread is thick, for example an EP4 thread, or the knot is very superficial. When Elasticum® EP 3.5 is used, ulceration of the knot is rare. If it does occur, it does so after several months, when the thread has become a stable ligament, at which time the knot can be removed without any untoward effect. The operator should take care to create a convenient pocket for the knot; if deemed necessary, a fragment of haemostatic collagen can be inserted into the incision, as seen in the video, in order to ensure that the knot remains deep.
Q) Is elastic lifting of the cheeks without blunt dissection preparatory to elastic MACS lifting?
A) Yes. Very often patients who undergo this type of procedure have an elastic MACS lift 5 or 6 years later, with skin removal. Similarly, patients who undergo elastic MACS lifting often request elastic neck lifting. This latter is a truly extraordinary procedure, in that it does not require dissection of the neck tissues.
A) Yes. The elastic thread and two-tipped needle are particularly useful for suturing wounds under tension, for example in round block of the areola or short-scar elastic arm-lifting, in order to draw together the edges of wounds in patients who are intolerant of re-absorbable dermal and subcutaneous sutures.
Q) It seems like an easy technique?
A) It is easy, though it does require precision. It is essential to realise that the anterior tip of the Jano needle® becomes posterior and the posterior tip becomes anterior whenever the needle changes direction. The fact that the elastic thread is anchored a few centimetres away from the wound means that the edges of the wound can subsequently be stitched without being under tension.
A) The patient wears an elasticated headband for a few days, which accelerates the disappearance of swelling.
Q) Does the direction of traction always have to be vertical?
A) The elastic thread has to be fixed to the temporal muscle fascia. Traction may be almost vertical, as in this patient, or oblique, in accordance with the patient’s wishes. If the traction is very oblique, dissection is carried out immediately above the deep temporal fascia.
A) Yes. In the video, we can see that the first circular suture has increased the prominence of the chin. The elastic thread, which is made of silicone, can also be utilised as a prosthetic implant; indeed, we have used it to raise the nasal floor in patients with labiopalatoschisis.
A) In this procedure, it is. Blunt dissection is subcutaneous and proportional to the amount of excess skin.
Q) Can it be deep?
A) If it is deep, i.e. at the level of the deep temporal fascia, dissection is even more limited and does not extend below the zygomatic arch.
Q) What are the advantages of the elastic MACS lift?
A) The advantages of the procedure are: great efficacy achieved through minimum invasiveness, lower risk of haematoma, maintenance of normal vascularisation and innervation, and the fact that this is an ambulatory procedure. As is well known, dissection damages the trophism of the tissues and increases both the risks involved and the duration of postoperative recovery.
Q) What precautions should be taken when the elastic thread is being implanted?
A) The operator has to study the face and mark out the pathway of the elastic thread. Once slight dissection has been carried out, the Jano Needle® is inserted into the subcutaneous tissue at the same depth. Moving the tip of the needle up and down slightly will indicate whether the pathway of the needle is becoming too superficial; if it is, the needle is withdrawn slightly and the trajectory is corrected. Once the two-tipped needle has reached the point of (partial) extraction, the posterior tip must not be brought too close to the surface, as the traction of the elastic thread would cause introflexion of the skin.
Q) What must be done if this happens?
A) The thread must be removed and implanted again. To avoid introflexion of the skin, the tip of the needle should be made to penetrate slightly more deeply before it emerges from the skin. The depth marks on the shaft of the needle help the operator to implant the thread at the correct depth.
Q) What must be done if the two-tipped needle is completely extracted by mistake?
A) In this case, too, the elastic thread must be removed and replaced.
Q) How long does it take for the elastic thread to be colonised by fibrohistiocytic cells?
A) This will depend on the vascularisation of the region where the thread is implanted. We can, however, suppose that colonisation occurs in three weeks and is completed within a few months. Moreover, we have the impression that applying physiological solution to the thread before implantation can accelerate its integration into the tissues.
Q) What about lifting the medial third of the face?
A) This procedure can be used to lift the medial third. If greater lifting is required, subperiosteal dissection of the malar region is performed through an incision.
Q) On the basis of your experience over the years, what suggestions would you make for operators who would like to start performing Elastic MACS lift?
A) The first thing is to insert the Jano Needle® accurately; the slight up-and-down movement of the tip helps to ensure that the needle is not too superficial, thus avoiding the creation of evident introflexion of the skin. Another suggestion is to wet the Elasticum thread with physiological solution. Finally, the right amount of skin must be removed, as this will affect the result. Naturally, suturing must be carried out in two layers and with care.
A) The elastic thread does not cut into the tissues and has the same consistency as the subcutaneous tissue. The two-tipped needle enables the cheeks and neck to be lifted without dissection; in the case described, dissection is minimal and the procedure is carried out in an ambulatory setting. In elastic lifting of the malar region, the first thread is implanted before subperiosteal dissection. As the malar region is dissected from the bony plane, it is gradually lifted by the elasticity of the thread. Clearly, then, it is very easy to achieve symmetry.
Q) Is subperiosteal dissection difficult?
A) Not only is it not difficult, it has never caused us any problems.
Q) How can the patient’s appearance be further improved?
A) These procedures are usually completed by means of Adipofilling®, which fills the space left by the removal of the parotid gland, thereby enhancing facial symmetry.
A) Little: 25 ml /30 ml of 1% lidocaine with epinephrine is enough.
Q) Does this operation avoid blunt dissection of the neck skin?
A) Yes. In traditional procedures, the neck skin has to be dissected. In this procedure, it does not. This means that the operation is far less traumatic; it can be performed in an ambulatory setting and healing is rapid. If the patient has long hair and no liposuction of the neck and cheeks has been carried out, she does not even have to take time off work.
Q) Can the procedure be performed even in the most severe cases of neck ptosis?
A) Yes. Obviously, the skin incisions and dissection will be more extensive and elastic neck lifting will have to be preceded by liposuction of the neck and cheeks. When the neck skin droops severely, there is always an excess of adipose tissue.
Q) Anchoring the thread to Loré’s fascia is very innovative, in that threads in the neck have always been anchored to the mastoid process. Does this new strategy involve any risks?
A) We have never had any problems. Loré’s fascia is thick and tough and the facial nerve is deep.
Q) Does the patient experience any discomfort after implantation of the thread?
A) No patient has ever complained after implantation of the elastic thread. Even if the thread is placed under considerable traction, it is perfectly accepted after a few days. It should also be pointed out that attaching the thread anteriorly avoids difficulties in breathing or swallowing. Elastic neck lifting is a truly extraordinary procedure and I am very glad to have invented it.
Q) When did you get this idea?
A) When I attended a course on face-lifting with anatomical dissection in Brussels. The course was held by two surgeons, Pelle Ceravolo and Botti, who proved to be very able teachers and who were very well-prepared (as indeed was the rest of their team). As I have always been interested in innovative techniques, I set about investigating the feasibility of deep face-lifting beneath of periosteum of the zygomatic arch, an idea that I have since abandoned. However, during the course, I realised that Loré’s fascia would make a perfect point of anchorage for the elastic thread. This idea fits in with the spirit of my procedures, which must be ambulatory, conducted under local anaesthesia, as efficacious as possible and minimally traumatic, involve minimal dissection and offer rapid restitutio ad integrum. If I think that one of my patients went out to dinner on the same day as she had undergone neck lifting, I am truly satisfied with this procedure!
Q) Is it possible to perform elastic neck lifting with a single thread, without making the submental incision?
A) Yes. In this case, the 16.5 cm needle is rotated through 180° and there is only one knot at the first entry point of the needle. Indeed, we now commonly use a single thread. Two elastic threads may, however, be used to tighten up the skin if there are residual skin folds under the chin.
A) The patient may feel swollen and drawn for the first two or three days, but once the oedema has subsided she will feel well. There is no respiratory constriction because the Elasticum® thread is anchored in an anterior position and lifts the slack tissues of the neck. The elastic thread raises these tissues and reconstructs the cervicomental and cervicomandibular angles that have been lost over the years. The elasticity of the Elasticum® thread obviously plays an important role.
Q) Through this technique of Elastic Plastic Surgery, an operation that used to require dissection of the cervical region from one side to the other can now be carried out in an ambulatory setting. How is it possible?
A) Try to imagine the neck tissues as a heavy curtain held in place by a lot of individual curtain-rings. During ageing, most of the rings come adrift and the curtain sags; the cervicomental angle disappears and two folds are formed (if four rings remain) or one large fold (if two rings remain). When the elastic thread is implanted, all the rings are raised and attached to a robust structure that will not sag: Lorè’s fascia.
Q) Will these patients remain satisfied?
A) Certainly. It is not unusual to see a pleasant, smooth face; what is more difficult is to see one above a handsome neck. A well-defined cervicomandibular angle confers an extraordinarily youthful appearance.
A) In this case, yes.
Q) What is the difference between elastic neck-lifting in men and in women?
A) Practically none. In men, the Jano needle is rotated three times because a man’s neck has a larger surface area than a woman’s.
Q) What are the advantages of such minimal blunt dissection?
A) The procedure is not very invasive; skin trophism is preserved as much as possible; the thread is not under tension; possible complications are extremely rare; the procedure is ambulatory and does not require hospitalisation.
Q) Which elastic threads are used?
A) For elastic MACS lifting: REF E3,5J1.3R115 (ELASTICUM® EP3,5 USP0+ Jano needle 115 mm); for elastic neck lifting: REF E3,5J1.5R165 (ELASTICUM® EP3,5 USP0+ Jano needle 165 mm).
A) Yes. The elastic thread is an extremely biocompatible and inert prosthetic material. It can be used with precision to correct bone defects that cause visible alterations.
Q) Have any of the patients that you have treated with the elastic thread suffered any complications?
A) No, we have never had any complications. The patient shown in the video had moderate itching for a few days; this resolved spontaneously without requiring any pharmacological treatment.
Q) What precautions need to be taken by surgeons who performed this procedure?
A) I suggest that they should bathe the elastic thread in a small amount of physiological solution enriched with an antibiotic. Bathing the thread enables it to be integrated more rapidly. A week of antibiotic prophylaxis is also advisable.
A) This procedure demonstrates that the elastic thread and two-tipped needle can be used to perform Neck Lifting without blunt dissection of the neck. In Elastic Neck Lifting, the tissues which are removed by means of blunt dissection in traditional procedures are utilised to restore the cervicomandibular angle. Therefore, it is almost never necessary to excise the skin in the preauricular region; thus, no visible scars remain. Elastic Neck Lifting is in an efficacious means of suspending the cervicomandibular angle and of tightening a slack submental platysma. If a more marked rejuvenating effect is desired, the operator can perform, either later or at the same time, an Elastic MACS lift, which helps to lift the superolateral region of the neck.
Q) In this procedure, do the neck folds no longer need to be removed by means of submental incision?
A) A simple test will answer this question. The fingers are placed on the angle of the jaw and the tissues are pushed upwards. If the neck folds disappear, they are gravitational.
A) The presence of excess skin is evaluated by pinching the skin below the sideburns with the fingers. If there is no excess skin and the patient wants to confer a triangular shape to the face and to contrast drooping, elastic lifting of the cheeks is performed, without dissection of the skin, through small 4 mm incisions. If there is skin in excess, MACS lifting is performed. With regard to elastic lifting of the temporal region and the eyebrows, this procedure is almost always carried out without blunt dissection. Elastic neck lifting can be performed through a 1 cm incision behind the lobe of only one ear, which is therefore not visible, and minimal dissection.
A) Restoring the cervicomandibular angle is very important, not only for the profile but also for the frontal view. When the neck recedes into the background, the outline of the face is enhanced, which creates a rejuvenating effect.
Q) Which other procedures are performed in Elastic Plastic Surgery of the neck?
A) If the skin under the chin is slack, two elastic threads that place the platysma under traction are also implanted, in addition to the thread that runs from side to side. In this case, the small incision and dissection of the skin above the fascia of Loré will need to be carried out on both sides of the face. Another procedure corrects the slackness of the lower part of the neck; two or more elastic threads exert traction on the subcutaneous tissues along a line that is anterior and parallel to the sternocleidomastoid muscle. The neck can also be rejuvenated by means of Adipofilling of the mandibular angle, of the posterior region of the face and of the subcutaneous tissue of the neck itself. Electroporo-cosmesis and needling, followed by the application of a saturated solution of resorcin, help to restore the firmness of the skin.
A) The technique used in this video should be explained. Elastic lifting of the eyebrows and temporal region is extremely efficacious and enables a permanent result to be achieved. The fact that no skin is removed and no visible scars remain means that both the operator and the patient need to change their way of thinking. This is due to the characteristics of the anatomical region and to the presence of the temporal fossa. If slight irregularities of the skin persist for more than six weeks, it is possible to perform Adipofilling in order to fill the temporal fossa or, in some cases, to implant a second thread in order to distribute any excess skin. In young patients, these corrections are almost never necessary.
Q) Which other procedures can be carried out in this region?
A) Upper and trans-conjunctival blepharoplasty, and Adipofilling to correct bags under the eyes and the lachrymal channel and to add volume to the malar region. Mixed peeling (de-epithelialisation and application of a solution of resorcin for a few seconds). The medial third of the face can very easily be lifted by means of the elastic thread and subperiosteal dissection of the malar region, and so on.
A) In all procedures involving the use of either the sharp two-tipped needle or the blunt two-tipped cannula, care must be taken to ensure that the cannula travels at a uniform depth. Slight up-and-down movements of the cannula help the operator to check that the pathway is not too superficial. If it is, the skin will be introflected and the cannula will have to be pulled back and repositioned at greater depth. The elastic thread must be bathed before being implanted; in this procedure, we prefer to use an antibiotic, such as gentamycin or clindamycin. Moreover, the elastic thread is delicate and must not be gripped with surgical instruments. The cannula must not be bent; rather, the tissues are bent. Normally, a quarter of a circle is completed at a time. The cannula with two rounded tips emerges from small 2 mm incisions made with a N° 11 blade. When the two-tipped cannula is being extracted through these micro-incisions, the operator must hold the attachment of the thread to the needle with his fingers. The attachment of the thread to the cannula must not be strained. The traction on the elastic thread as the cannula passes through an incision of a few mm is very great; this traction must not be transmitted to the attachment of the thread to the cannula because the elastic thread might be cut by the edge of the anchorage hole and be detached from the cannula. Finally, the volumes to be lifted should be considered. If the volumes are considerable or the patient is tall, it is preferable either to run the elastic thread round twice at each encirclement, or to implant two separate elastic threads with two knots, both of which will be housed in the same incision. This ensures greater holding over time.
Q) Which patients can undergo this ambulatory procedure?
A) All patients with drooping buttocks.
Q) What precautions does the patient need to take in the post-operative period?
A) For at least two months, the patient must avoid straining the threads; she will have to sit down gently, sleep in a prone position or on a side, and wear a push-up girdle. The girdle effectively helps to eliminate post-operative pain. Within a short time, the elastic thread will be colonised by fibrohistiocytic cells and the result will remain stable.
A) Suspension is permanent because it is carried out between two fixed points, the two fasciae of Loré.
Q) What advantages does using the suspensive elastic thread have over the traditional procedure?
A) Suspensive elastic neck lifting after liposuction to treat a double chin enables an excellent result to be achieved immediately. The cervicomandibular angle is much better defined and the jaw also becomes well delineated. By eliminating the weight of the tissues, elastic suspension allows complete retraction of the area subjected to liposuction. The elastic thread is neither visible nor palpable, and becomes integrated into the tissues within a few weeks after implantation.
Q) In patients with excess skin, might it be useful to run the liposuction cannula through several times, without aspirating, in order to facilitate retraction of the skin?
A) Yes, it could be very effective. Reducing the subcutaneous tissue could be useful in any case. Moreover, slackness of the platysma muscle and skin under the chin can easily be corrected by implanting another two elastic traction threads and anchoring them to the two fasciae of Loré.
Q) How do you draw out the exact pathway where the suspensive elastic thread is to be implanted?
A) The surgeon and the assistant press the skin upwards above the angle of the jaw. The patient has to bend his neck until the cervicomandibular angle appears; this is then marked out with a dermographic pen.
Q) In cases of “turkey neck”, is there no longer any need to make an incision under the chin and to remove a portion of the platysma?
A) An incision under the chin is almost never made. The elastic thread is able to suspend the tissues of the neck, restoring them to their original position. All defects can be corrected by means of the elastic thread, without blunt dissection and without the removal of skin. In the most severe cases, the skin can be treated by means of Electroporo Cosmesis, followed by the application of resorcin. When the skin is no longer subjected to the pull of gravity, it rapidly shortens and is remodelled.
A) The procedure can be repeated; this time, an incision a few millimetres long will be made in the angle formed between the contralateral anterior wing of the nose and the lip. The surgeon must bear in mind the number of runs of the EP4 elastic thread made during the previous procedure and carefully evaluate the pre- and post-operative photographs, in order to decide how many runs of the two-tipped needle will be required.
Q) Are the knot and the thread palpable?
A) In this procedure, the knot is buried in the bony fossa situated beneath the small skin incision. The elastic thread is not palpable, even though it is implanted immediately beneath the dermis, because it has the same consistency as the subcutaneous tissue.
Q) In patients with an acute naso-labial angle, the tip of the nose usually moves when they speak. After this procedure, does the tip of the nose move more or less?
A) After this procedure, the naso-labial angle becomes obtuse, the base of the nose is narrowed, the tip of the nose is raised, the nose appears shorter and the features become less sharp. The tip of the nose moves less because the procedure reduces the excessive mobility of the naso-labial muscles.
A) This has never happened. The implantation plan is safe and the operator feels the resistance caused by the tissues as the needle is passed through.
Q) Can the base of the nostrils be narrowed?
A) Yes. Only 5 mm of the needle tip needs to be left in the tissues.
Q) Is it possible to increase the nasolabial angle only in the central portion of the lip?
A) Yes. In this case, the length of the tip which remains in the tissues is about 1 cm.
Q) Is the elastic thread implanted in the muscle or in the peri-maxillary tissues?
A) In the muscle. Only if we wish to raise and stabilise the height of the lip is the elastic thread implanted in contact with the maxilla, where it is anchored. Raising the upper lip and increasing the nasolabial angle at the same time is another procedure that has been made possible by the elastic thread and two-tipped needle.
A) As this is a recent procedure, we do not know its limits yet. Nevertheless, it clearly exerts a preventive action on gravitational ptosis of the upper lip. This procedure can be recommended for young subjects with a familial tendency to lengthening of the upper lip. A severely drooping upper lip always requires two threads, both of which extend to the lower half of the lip.
Q) Can the elastic thread also be utilized in the traditional procedure involving skin excision?
A) With elastic suspension of the lip, the scar left by the traditional procedure can be of better quality. We always aim to avoid leaving scars. We strive to facilitate retraction of the skin, which is no longer subjected to the weight of the underlying tissues, by means of physical and/or chemical methods. Our current studies are focused on achieving this objective.
Q) Is the elastic thread anchored to the maxillary tissues?
A) The Jano needle travels through the premaxillary fibrous tissues to anchor the elastic thread. The operator skims the bone and checks the anchorage by moving the two-tipped needle. The resistance felt as the needle travels through the tissues lets the operator know that the pathway is correct.
A) Numerous procedures can be carried out to treat the lower third of the face; one of these is volumetric revitalisation with 10% or 20% macrolane. This technique, which is performed several times, can elicit an increase in the thickness of the hypotrophic subcutaneous tissue. An even more efficacious technique is Adipofilling, which involves injecting a cellular suspension of adipocytes and stromal cells.
If there are slight bulges and volume discrepancies in the area around the marionette wrinkles, we normally adjust the outlined by means of the timedsurgery Adipolysis technique at 38 Watts (Program data: Direct Pulsed 0,3/5,3, Coag.) . Several micro-tunnels are created – always in the direction of the retraction that we wish to achieve – by means of the partially insulated EM 10 Grey and EM 10 Green Electromaniples. The same programme data are utilized in the reduction of malar pouches, though nowadays these are more frequently corrected through volumetric enhancement of the area.
Q) What is the aim of these procedures?
A) To restore the triangular shape and the outline of the face. Liposuction eliminates excess volumes, and the subcutaneous retraction that it causes helps to improve the result. It should be borne in mind that the tissues in which the thread is implanted will no longer tend to stretch (as the thread is rapidly transformed into a “ligament”). The threads prevent and delay drooping.
Q) As we have seen, when you have finished suturing, you press the suture with the needle-holder. Why?
A) To bring the edges together more firmly. To this end, I also advise knotting the suture alternately on one side and then on the other.
A) When I was 19 years old, I used to assist my mother when she was performing face lifting. After 35 years of working in the operating theatre, I came to the conclusion that face-lifting needed to be completely modified. For what concerns suspension by means of threads, the idea is by no means new. My mother’s plastic surgery manuals already described procedures for the stable correction of facial nerve paralysis by means of strips of fascia lata. The concept of correction close to the defect was already known, and the results were highly satisfactory. The elastic thread has proved eminently able to replace these strips of biological material, and the 2-tipped needle has enabled traction and suspension to be carried out without
having to dissect the tissues. To all this, we have added the ability to transpose the tissues by exerting traction by means of subcutaneous sutures; these sutures are often arranged in a triangular fashion, and all the tissue encompassed by the triangle is repositioned. This repositioning achieves filling where it is necessary and gives the patient a natural and much younger appearance.
Q) Is the width of the base of the equilateral triangle that is fixed to the temporal fascia or to the subcutaneous tissues in the latero-cervical region proportional to the volume of the tissues to be lifted or transposed?
A) Yes. In order to lift the cheeks, we anchor the elastic thread to the temporal fascia and create a triangle that is proportional in size to the volume to be lifted. In the neck, the elastic thread is anchored to the Lore’s fascia and to the the latero-cervical subcutaneous tissues; as the tissues are displaced sideways, the scrawny appearance of the neck is also corrected. The triangles are particularly efficacious and are always proportional in size to the volumes and the surfaces on which they act.
Q) In these elastic lifting procedures, why is such importance attached to the posterior regions of the face and neck that are to be enhanced through the transposition of the tissues?
A) While the interior regions of the face and neck are obviously important, the posterior regions are just as important, as these contribute to a youthful appearance. Removing the lateral tissues of the cheek and neck often creates a “post-lifting” appearance, with the skin drawn tight and the face pointed; this is unnatural and makes the patient appear old.
Q) In traditional lifting procedures, there is typically a scar that starts in front of the ear, runs around the lobe and up over the mastoid region, and ends up in the neck. Does this ever happen in elastic lifting?
A) No. We do not dissect the skin of the neck, nor do we remove it; we simply shift the tissues by means of a 5 mm incision. In this way, the result is clearly visible, but natural and “soft”. The tiny incisions are negligible. What is more is that this is an ambulatory procedure and the patient can go home after half an hour.
Q) Aren’t there any problems with excess skin?
A) When neck lifting is carried out by implanting an elastic thread between the two fasciae of Loré, the excess skin of the cheeks is reduced, becoming negligible. As we have said, the skin and subcutaneous tissues of the neck are repositioned laterally.
From the conceptual standpoint, this is a highly innovative surgical procedure which enables us to correct all defects simply.
However we are studying procedures that rejuvenate where facelift do not act.
A) In surgical mastopexy (A) the elastic thread is implanted at a depth of about 1 cm or 1.5 cm. The normal scheme of elastic mastopexy is generally followed; there may be variations in the preoperative design, but only in particular cases. When the breast is being prepared for Adipofilling (B), the implantation depth is the same. In elastic mastopexy, the depth is 1.5 cm. In the remodeling of breasts with silicone implants, the elastic thread is implanted at a depth of 5 mm.
Q) Which elastic threads are used in elastic surgery of the breast?
A) We use the Elasticum EP4 thread mounted on an 11.5 cm Jano needle. In surgical mastopexy, the circular suture around the areola uses the elastic threads mounted on a 3/8 circle needle.
Q) Breasts with large silicone implants always have an artificial look. This new and simple Elastic Plastic Surgery procedure restores their natural appearance. Do you think it can improve the appearance of breasts with medium-sized and small implants, too?
A) Yes. Conization of the apex makes the breast look more “natural” and pleasing, even if the implant is medium-sized or small. The circular suture prevents the apex of the breast from flattening and losing its conical shape over time. If the apex is conized, the breast does not look as if it has been operated on.
When silicone prostheses are implanted in small breasts, the areolae normally become dilated. With our procedure, the diameter of the areola remains small and the breast maintains a youthful look. Finally, conization, in addition to shrinking the apex of the breast, broadens its base; the breast becomes more compact.
Q) Can this procedure also be carried out in mastopexy operations?
A) Certainly. In elastic mastopexy, we not only conize the breast by means of two circular sutures; we also implant a third thread to lift the breast. In effect, we anchor the breast to the subcutaneous tissues of the chest. Moreover, this third thread compacts the tissues, thus giving the upper pole rotundity. In Elastic Plastic Surgery, we can perform mastopexy by means of only two small skin incisions of a few mm. If there is a small volume deficit, it is corrected by means of Adipofilling.
Q) By how much is the breast raised by these procedures?
A) That depends on the type of procedure. Second-degree ptosis becomes first-degree, while first-degree ptosis becomes normal. It all depends on the content of the breast, on the container, on the number of elastic threads implanted and on the availability of adipose tissue for Adipofilling. The preoperative design is also important. For example, the lower half of the conizing circle is drawn while the patient is standing up; the upper half is drawn while the patient is lying down.
Q) Is there no vascular risk in implanting the circular sutures?
A) No. Vascularization is maintained and the small skin incision produces negligible damage.
Q) If the breasts are very heavy, is there anything else that should be done?
A) The elastic thread can be taken round twice instead of once, and the number of elastic threads can be increased. Personally, however, I prefer to maintain the three suspension threads. In order to correct a defect in shape, I can also add another elastic thread during the same procedure. If the patient wishes to improve the breasts further, additional elastic threads can be implanted. However, this will necessitate a new suspension procedure and, as such, will need to be considered in all its aspects.
Q) Are the results maintained over time?
A) Yes. The results are permanent because the elastic threads are integrated into the tissues and transformed into ligaments.
Q) Are there any problems regarding mammography and echography?
A) No problems.
Q) After elastic mastopexy, any asymmetry of the breasts seems to be more noticeable. How is this corrected? By means of Adipofilling?
A) After all mastopexy procedures, any asymmetry is more noticeable. Indeed, it is difficult to perceive this asymmetry when drooping breasts lose their conical shape and sag against the chest. Yes, we correct volume deficits by means of one or two sessions of Adipofilling. It should also be remembered that the elastic thread and the two-tipped needle can be used to recruit chest skin as if it were part of the breast.
A) es. The Jano needle enables the elastic thread to be implanted exactly where it is needed, close to the visible defect. Moreover, the thread is colonized by fibrohistiocytic cells within a few weeks and is transformed into a ligament. The cutaneous and subcutaneous tissues return to their natural position and are not removed.
The drooping of the neck tissues is the result of the gravitational ptosis of the face, even though it can be treated separately, such as in the case of double chin, for instance.
Let’s take a couple of examples. If we are faced with a drooping neck, we place both hands on the two angles of the jaw and raise the skin; the folds in the neck disappear. This is what happens when we do a MACS lift, which leaves a small scar that runs around the sideburn and stops at the tragus. In this case, the excess vertical skin is removed (this is the only case of skin removal in elastic lifting of the face). The newly implanted ligament supports the supero-lateral portion of the neck.
The elastic thread running between the two fasciae of Loré restores the cervico-mandibular angle. The first pathway of the elastic thread is exactly at the depth of the cervico-mandibular angle. The return pathway of the thread may be about 1 cm above the previous one, as in this case of double chin, or about 1 cm below the previous one. In the former case, the thread supports the tissues under the chin; in the latter case, it lifts the anterior and lower tissues of the neck. Restoring the cervico-mandibular angle reduces the excess skin. If we were to dissect the skin of the neck and the skin anterior to the ear, the excess skin would cover 2/3 of the ear. However, once the elastic thread has been implanted between the two fasciae of Loré, the excess skin is reduced to less than ½ cm. Indeed, almost all the excess skin serves to restore the cervico-mandibular angle. Obviously, there is no point in dissecting the area and creating a pre-auricular scar, which will always remain visible, in order to remove a small amount of skin, which, as it is no longer subjected to traction, easily diminishes and becomes irrelevant.
For what concerns the submental region, I personally recommend checking for the presence of excess adipose tissue, even as little as a few cc. This can be aspirated with a 2 mm diameter cannula through two small lateral incisions made with a N° 11 blade. Liposuction must be rigorously horizontal in order to exploit the retraction of the scar. Following liposuction of a double chin, it is very important to maintain elastic compression for three weeks.
If there is no excess adipose tissue, the correction and prevention of skin folds under the chin are carried out by implanting an elastic thread on both sides; this thread is anchored to the fascia of Loré and applies traction to the platysma immediately below the mandibular arch. The two-tipped needle is used to implant the thread and, naturally, no dissection is carried out.
The last procedure described in this video is elastic lifting of the lower neck, which lifts and applies traction to the anterior portion of the neck. These procedures can be completed by peeling, which makes the skin firm. We use physical/chemical peeling with resorcin.
Q) Is elastic lifting of the lower neck the last procedure to be carried out on the neck?
A) Normally, yes. Elastic lifting of the lower neck is carried out last. As slight differences in the slackness of the tissues between the right and left regions of the neck may emerge after the procedure, another elastic thread can always be implanted.
Q) Are there any problems with the veins, for example the external jugular?
A) If there are evident veins, we mark them out and, if necessary, we create a small tumescence above the vein; this enables the two-tipped needle to pass over the vein without risk. However, we have never encountered any significant bleeding.
Q) Where do you recommend making the small incision through which the 16.5 cm Jano needle is inserted: at the upper angle of the base of the isosceles triangle or at the lower end?
A) I prefer to insert the needle through a 3 mm incision made at the upper angle of the base of the isosceles triangle. I find it easier to insert the Jano needle and to anchor the elastic thread to the subcutaneous nuchal tissue from above.
Q) Compared with traditional procedures, the mentality here seems to be different.
A) Yes, it’s very different. We implant a predetermined number of elastic threads. Once the technique has been mastered, the results are always very good. If, a year later, the patient has a desire for further improvement, we implant further elastic threads. Let’s take an example: suppose we implant four elastic threads in order to lift the buttocks. If one buttock has a slightly different shape, owing to a natural asymmetry, we can simply implant another elastic thread. Another example: we lift the breasts by means of four elastic threads. Two years later, the patient decides to lift the breasts further; in this case, we implant another two threads.
In practice, these procedures, especially in patients with a high degree of ageing, utilize the implantation of elastic threads. Let’s take another example. Suppose we carry out a first-time procedure of MACS and elastic neck lifting in an elderly patient; at the same time, we implant two threads to lift the submental platysma and perform liposuction of the double chin. The MACS lift will not need to be repeated, as the drooping of facial volumes and stretching of the skin are prevented by six ligaments implanted in the cheeks. In a second procedure, we perform elastic lifting of the temporal region and lower neck and peeling of the neck. A further procedure will then be carried out to reduce wrinkles and to perform Adipofilling of bags under the eyes, the nasolabial folds, the temporal fossa, the area around the mouth and the cheeks. In this way, suspension is combined with the volumetric and biological effects of the adipose and stromal cells and of peeling. The patient is completely rejuvenated and has a natural appearance, which is our main objective.
Korpo thanks Medical Video Journal CRPUB.ORG open access for the material placed at our disposal.