ORIGINAL ARTICLE FACIAL SURGERY

Elimination of Aesthetic Deformations of the Midface Area OurExperience

Marlen Sulamanidze1,2 • George Sulamanidze1,2 • Constantin Sulamanidze1,2

Received: 15 September 2017 / Accepted: 18 February 2018

� Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2018

Abstract

Introduction The aesthetic manifestations of the aging

process in the cheekbone, cheek and infraorbital areas are

especially concerning for patients, so rejuvenating inter-

ventions in these areas are most in demand.

Objective To introduce the experience of our clinic for

aesthetic manipulation using Aptos (anti-ptosis) thread

lifting methods in the midface area.

Methods Among the surgical interventions that we used

were Aptos thread lifting methods both in combination

with lower blepharoplasty, and without it. At the same

time, special attention was paid to the individual approach,

trying to minimize invasiveness and, most importantly,

trying to achieve the effect of moving subcutaneous soft

tissues to a new, more advantageous position from an

aesthetic point of view, with their fixation to dense

structures.

Results The results of application of the presented methods

to lift the cheek–zygomatic and infraorbital regions using

Aptos methods were studied. In the overwhelming majority

of cases, the results satisfied both surgeons and patients.

Conclusions Aptos methods for lifting the midface soft

tissues, which we used, are quite effective for rejuvenating

the aging face.

Level of Evidence IV This journal requires that authors

assign a level of evidence to each article. For a full

description of these evidence-based medicine ratings,

please refer to the Table of Contents or the online

Instructions to Authors www.springer.com/00266.

Keywords Midface � Face lift � Nasolacrimal furrow �Nasolabial fold

Introduction

In the last 3 decades, aesthetic surgery on the midface area

began to develop rapidly. There were always significant

preconditions for this: patients and surgeons noted that the

visual signs of facial aging are more sharply manifested in

this area. Ptosis of the infraorbital soft tissues and buccal

areas, fat hypotrophy, and consequently, appearance of the

nasolacrimal furrow and infraorbital depression, aggrava-

tion of the nasolabial fold were always considered signs of

a dull, sluggish, aging face. The increasing demand for

interventions to eliminate such deformities encouraged

surgeons to improve the classical and develop new meth-

ods for contouring and lifting the middle zone of the face.

Among them are endoscopic lifting, contour plastic

implants, autologous fat, fillers, thread suspenders, skin

peels, etc.

Possessing certain advantages, each of them has limi-

tations that do not allow manipulation or operation in all

cases, regardless of the volume and nature of the defor-

mation [1–8].

Electronic supplementary material The online version of thisarticle (https://doi.org/10.1007/s00266-018-1112-3) contains supple-mentary material, which is available to authorized users.

& Constantin Sulamanidze

gracia@aptos.ru; info@aptos.ge; office@aptos.ge

1 Limited Liability Clinic Total Charm and APTOS Company,

Moscow, Russia

2 Limited Liability Clinic Total Charm and APTOS Company,

V. Orbeliani str. 18, Tbilisi, GA 0105, USA

123

Aesth Plast Surg

https://doi.org/10.1007/s00266-018-1112-3

Materials and Methods

From 2003 to 2008, for the lifting of flabby soft tissues in

the middle zone of an aging face, several minimally

invasive surgical techniques have been developed in our

clinics, which are currently used in our daily practices.

Among them are thread liftings—Aptos Thread 2G, Aptos

Needle 4/0 and Aptos Needle 2G. This report presents the

most frequently used operations and manipulations in our

clinics as invasive, involving the application of a surgical

incision, and without disrupting the integrity of the skin,

through a puncture [9–11].

For all this time (6 years), 1226 operations were per-

formed by the main author using the given methods. Aptos

Thread 2G method—736 procedures, Aptos Needle 2/0

method—330, and Aptos Needle 2/G method—160

patients. From the total of 1226 patients, 1028 (84%) were

women aged 30–60 years. The percentage of patients aged

between 35 and 50 years was 67%. In our experience, this

is the age group in which the best results are achieved by

Aptos methods.

Aptos Thread 2G Method

It is performed with the help of a special suture material,

which consists of two needles (100 9 0.9), to the ends of

which atraumatically is attached a thread with multidirec-

tional barbs (prolene or a thread of polylactic acid 2/0,

25 cm long). The tips of the needles have a special oblique

sharpening and joined together they make up one spear

point, which allows the injection of both needles into the

skin at a time through one puncture and to separate them at

the required depth. Thanks to the realization of the original

idea of pairing two needles, the operation was performed

without incision and skin retraction (Fig. 1a, b).

Operation Technique

The point of injection was determined in the projection of

the zygomatic arch about 3–4 cm from the lateral cantus.

The paired needles were inserted with a single point to the

periosteum, and here they were separated and alternately

were passed according to the marking (Fig. 2). At the same

time, the fingers of a free hand pulled up soft tissues of the

infraorbital, malar and partially buccal areas, creating a

lifted, high contour of this zone, and the other hand pushed

the needle. The needles and, accordingly, the threads were

passed along the contour of the bowstring (video animation

No. 1), i.e., after injection and separation, the tip of each

needle was gradually deepened to the middle of the pull-up

area and from there was also gradually lifted toward the

dermis to the exit point near the nasolabial fold. Thus, the

whole thread was passed in the SMAS of the molar and

infraorbital regions, which usually corresponded to the

projection of the nasolacrimal groove, thereby pushing out

the tissues of the furrow itself more proximally achieving

visual smoothing. After the removal of both needles, the

soft tissues and the ends of the threads were pulled up, the

remains were cut, and the tips were buried under the skin.

At the same time, the bend of the thread slipped under the

skin to the point of divergence of the needles, where it

clung to the periosteum of the zygomatic arch. This

adhesion significantly strengthened and stabilized the

Fig. 1 a Aptos Thread 2G for

suturing soft tissues of the

infraorbital and cheek–

zygomatic areas (scheme).

b Jointed needles Aptos Thread

2G

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entire structure of the lifting effect of the midface zone,

because the inflection of the thread did not engage the

dermis, but slipped deeper to the point of divergence of the

needles, and the skin retractions did not appear (video

animation No. 2 and intraoperative video No. 1).

Aptos Needle 4/0 Method

The given method was applied for lifting the soft tissues of

the midface area, as an independent operation, so in com-

bination with classical or transconjunctival blepharoplasty.

These interventions were performed using a special sutur-

ing material, which is a 6-cm-long curved needle with a

smooth thread—prolene 4/0, 60 cm long (Fig. 3), attached

to the needle in its middle part. This product has the ability

of two-way patency, allowing to carry the thread under the

skin and subcutaneous suturing of soft tissues along the

oval in the form of a purse-string, round or elongated

contour without skin retractions and obtaining a smooth

tightened contour.

Operation Technique

Depending on the degree of ptosis and the severity of the

tissues, the presence of a lacrimal sulcus and the depth of

its occurrence, we developed several modifications of the

intervention for lifting of the infraorbital and cheek—malar

areas, but in this report, we will consider the most fre-

quently performed operations. Figure 4 shows the marking

of an independent intervention, according to which, along

the ‘‘crow’s foot’’ wrinkle, a 2–3 mm long incision was

made, up to the periosteum of the eyebrow edge, then

widened the duct with a thin mosquito-type clamp. The

Aptos Needle 4/0 point was inserted into the given duct in

such a way that it grasped the periosteum. The fingers of

the free hand helped to place the tissues of the infraorbital

and cheek–zygomatic areas in a tightened position, the

needle was guided along the marked oblique contour,

alternately extracting it and changing the point, turning it

and returning to the wound. Here, both ends of the thread

were tightened and tied to the periosteum with several

knots. Similarly, the second and third sutures were applied

according to the marking. All together, these multi-vec-

tored, intersecting sutures created a new, high, aesthetically

Fig. 2 Marking scheme for suturing soft tissues in the middle zone of

the face Aptos Thread 2G

Fig. 3 Aptos Needle 4/0 for suturing soft tissues of the infraorbital

and cheekbone areas

Fig. 4 Marking scheme for suturing soft tissues of the midface area

using Aptos Needle 4/0—an independent operation

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more favorable contour of soft tissues, with smooth tran-

sitions to neighboring areas (intraoperative video No. 2).

The same lifting was performed simultaneously with

classical or transconjunctival blepharoplasty. In this case,

suspension points of the three ‘‘purse-string suture’’ sutures

were determined in different places of the arcus marginalis

(Fig. 5).

Aptos Needle 2G Method

The given method is performed using a special suture

material that absorbed the positive qualities of Aptos

Thread 2G and Aptos Needle 4/0.

This product is composed of a prolene thread or a 2/0

polylactic acid thread, 50 cm. in length, with multidirec-

tional barbs converging to the middle part. The thread is

connected to two double-pointed needles in their middle

part by its ends (Fig. 6). The length of each needle is

10 cm. Also, like the Aptos Thread 2G, the needles are

paired in such a way that one point can be punctured into

the skin through one injection. In the depths of tissues,

dividing the needles, you can pass each one separately

according to the marking in different directions.

Operation Technique

The combined tips of the Aptos Needle 2G were inserted

according to the marking (Fig. 7) into the area of the

zygomatic arch up to its periosteum, where they were

separated and alternately passed through fatty tissue alongFig. 5 Marking scheme for suturing soft tissues of the midface area

using Aptos Needle 4/0—simultaneously with blepharoplasty

Fig. 6 Aptos Needle 2G for suturing soft tissues of the infraorbital

and cheek–zygomatic regions (scheme)

Fig. 7 Marking scheme for suturing soft tissues of the midface area

with Aptos Needle 2G

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the planned lines. The needles exited at the marked points

partially, were turned and returned by another point to

another trajectory. Thus, both needles, followed by a thread

attached to them, bordered the area of the middle zone of

the face in the form of two purse-string sutures, and the

inflection of the thread in its middle part slipped to the

periosteum of the malar bone and was firmly fixed there.

Simultaneously with the passage of the needles and the

moderate tightening of the threads, a high, lifted volume of

soft tissues of the infraorbital and cheek–zygomatic regions

was created with the fingers of the free hand. At the exit

point of the thread ends and their final tightening, the

excessive ends were cut off and buried under the dermis

(video animation No 3). At the same time, there was no

need for suturing, because the barbs along the entire length

of the thread firmly fixed to the underlying fibers. Addi-

tional fixation of the purse-string sutures was provided due

to the stable engagement of the tissues with the inflection

of the thread both in the zygomatic arch area and in the

nasolabial fold region. Thus, they created a high even

contour of the midface zone, eliminated the nasolacrimal

furrow and somewhat smoothed the nasolabial fold, with-

out producing skin incisions.

This technique proved to be more reliable than Aptos

Thread 2G due to the creation of two purse-string con-

structions, 3 bends of the purse-string sutures and the

diversification of lifting. This technique was also more

effective than Aptos Needle 4/0, because it did not require

skin incisions and surgical knots, and Aptos Needle 2G

thread had barbs that evenly grabed soft tissues throughout

its entire length.

In the overwhelming majority of cases, infiltration

anesthesia was used in the above-mentioned operations and

manipulations: Lidocaine Sol. 1% with adrenaline or epi-

nephrine, but no more than 4–6 ml on one side, was

injected along the markings.

Fig. 8 a, b, c, d Patient P: 38-year-old, before and 3.5 years after correction of the midface area with Aptos Thread 2G

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Usually, any of the described operations were carried

out easily and quickly, the tissues were inflicted with minor

trauma, the result of the intervention was already visible on

the operating table.

After the operation, sterile stipes were placed on the

wound (or puncture) for 1–3 days.

Results and Discussion

The technologies of the presented methods were developed

on the basis of clinical experience, studying the literature

on topographic anatomy taking into account the age

Fig. 9 a, b, c, d, e, f. Patient L: 50-year-old, before and 2 years after correction of the midface area with Aptos Thread 2G

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changes that occur in the aging process of the organism

[12, 13].

Soft tissues of the midface zone are fixed to the

periosteum of the zygomatic bone and the lower edge of

the orbit (arcus marginalis) by means of fibrotic folds, and

also are suspended to the vascular-neural bundle emerging

from the canalis infraorbitalis. According to the modern

morphological studies, these structures gradually weaken

over time, atrophy and stretch. Soft tissues or so-called fat

compartments are influenced by ptosis together with them,

creating a new ‘‘landscape’’ of the midface zone skin. In

our clinical practice, we have almost always noted that the

periosteum of the upper jaw, zygomatic bone and its arch,

and also of the neurovascular bundle change their position

with time, they practically do not stretch and accordingly

do not weaken. Only their connections with more mobile,

loose structures, which include subcutaneous fat of the

infraorbital and nasolabial areas are weakened and

stretched during some period of time, thus ptosis of these

parts is especially intensive. Probably, at a young age this

fat aggregation constitutes two compartments of this face

area and SOOF. The anatomy of the zygomatic area (the

third compartment) is somewhat different: here the fatty

tissue is tighter, penetrated with fibrotic folds and tightly

jointed to the underlying periosteum, so clinically, this area

is not highly prone to ptosis. Soft tissues of the infraorbital

and buccal areas are partially supported due to the con-

nections with the fatty tissue of the zygomatic area.

As a result of the weakening and stretching of the

fibrotic folds and ligaments between the arcus marginalis

and the infraorbital fat structures and, accordingly, ptosis

of this part of the midface zone, a palpebromalar (in-

fraorbital) furrow appears, aggravating the retraction near

the ‘‘eyelid–cheek’’ border. Also, as a result of the weak-

ening and stretching of the bonds between the zygomatic

fat and the fatty tissue of the infraorbital area and,

Fig. 10 a, b, c, d Patient S: 35-year-old, before and 1.5 years after correction of the midface area with Aptos Thread 2G

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accordingly, the ptosis of the latter, a nasolacrimal groove

appears. This is sometimes accompanied by the ptosis of

the fatty tissue of the cheek and the appearance of a

depression beneath the cheek fat. In this process, the

hypotrophy of the fatty tissue of the infraorbital region is of

a great importance too, a decrease in the volume of this

zone significantly worsens the aesthetic effect of the whole

face [14, 15]. As a result, the middle zone of the facial soft

tissues is divided into three sections (a compartment)—the

cheekbone, the infraorbital and the nasolabial, which are

Fig. 11 a, b, c, d Patient T: 32-year-old, before and 1 year after correction of the midface area with Aptos Thread 2G

Fig. 12 a, b Patient C: 50-year-old, before and 2.5 years after suturing the midface area with Aptos Needle 4/0

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clearly manifested clinically. Due to the ‘‘sliding’’ of the

nasolabial area of the midface zone down and medially (the

first compartment), its hypertrophy also aggravates the

nasolabial fold. The weakening of bonds and fibrotic folds

between the cheek fat and the fibers of the cheek (buccal

fat, Bichat‘s fat pad) and, accordingly, its ptosis gradually

lengthens and deepens the nasolacrimal furrow.

Thus, instead of a single convex smooth contour of the

skin of the midface area with smooth transitions to

neighboring areas, i.e., the landscape of the young face, the

zygomatic, nasolabial and buccal regions visually manifest

themselves with age, and the suborbital region practically

appears in the form of a retraction.

In accordance with these conclusions, we set the task of

developing methods that would allow a ‘‘return’’ of the

divided sections of the midface soft tissues to the ‘‘old’’

place, to unite them with new connections—thread sutures

without surgical operation.

Due to our experience, the manual movement of all and

each compartment of the midface zone, soft tissues freely

and easily move upwards and laterally, so they do not need

operational mobilization.

Taking the given circumstances into account, the mini-

mally invasive Aptos methods have been developed,

which, depending on the indications, allow linear, circular,

purse-string, skeletal or elastic suturing of the soft tissue

ptosis of the midface zone, their lifting and stable fixation

to denser structures. Above we presented the techniques of

the most frequently used manipulations.

Let’s analyze each of the presented methods of lifting

the middle zone of the face and the results that can be

obtained with their help.

According to the Aptos Thread 2G method, thread lift-

ing of the midface zone is created due to a somewhat

oblique but linear direction suspension to the periosteum of

the malar bone arch and barbs on the thread. Tough sus-

pension of the barbed thread occurs due to the flexure of

the thread in this section.

When performing this manipulation, both threads were

passed through dense zygomatic fat, under the nasolacrimal

furrow and further into the nasolabial fat region. ‘‘Return’’

of nasolabial fat under the ‘‘patronage’’ of the zygomatic

area was carried out due to manual transfer of soft tissues

of this site and their threading on the barbs of the tightened

threads. This eliminated the nasolacrimal furrow, aligned

the contour and smoothed the nasolabial fold (Figs. 8a–d,

9a–f).

Manipulation according to this version also allowed

moving and suspending tissues of not only the nasolabial

but also the infraorbital and buccal areas to the periosteum,

the arch of the malar bone and fatty tissue of the zygomatic

area, increasing the volume of the raised tissues, and

eliminating the nasolacrimal groove all along and

smoothing the nasolabial fold (Figs. 10a–d, 11a–d).

The disadvantage of Aptos Thread 2G methods is the

fact that although in the area of the zygomatic arch the

attachment is fairly stable (due to the attachment to the

periosteum of the inflection of the thread), the threads are

passed linearly along a slightly curved path, and their ends

do not attach to dense structures and remain in a free state.

Fig. 13 a, b The same patient

cFig. 14 a, b, c, d, e, f, g Patient H: 54-year-old, before, immediately

after intervention, 1 year and 5 years after classical lower blepharo-

plasty and correction of the middle zone of the face with Aptos

Needle 4/0

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This circumstance weakens the entire structure and,

accordingly, the stability of the lifting—recurrence of

aesthetic deformation, happens on average after 2 years. At

the same time, of all the three methods presented Aptos

Thread 2G is the least traumatic and easy to perform for

surgeons. Postoperative rehabilitation is shorter and

therefore the technique is in demand among doctors and

patients.

Fig. 15 a, b, c, d, e, f Patient E: 40-year-old, before, 20 days and 1 year after suturing the midface area using Aptos Needle 4/0 simultaneously

with transconjunctival blepharoplasty

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Therefore, in cases in which the ptosis of the tissues was

more pronounced, when it was necessary to significantly

move the skin-fat layers, the volume of tissues was large

and when there was a need to have long lasting results

(3–4 years or more), we applied Aptos Needle 4/0 or Aptos

Needle 2G, which did not have free ends of the thread and

created a rigid fastening of the lifted tissues at several

points, due to the purse-string structure, which also had

different vectors.

Fig. 16 a, b, c, d, e, f Patient C: 58-year-old, before and 0.5 years after midface correction with Aptos Needle 2G

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The Aptos Needle 4/0 method, as an independent

operation, allowed suturing, moving and stable tissue fix-

ation of the nasolabial and buccal fat tissues to the

periosteum of the orbit margin in the projection of the

lateral cantus, as well as the removal of the nasolacrimal

fissure along its entire length and smoothing of the palpe-

bral fossa and nasolabial folds (Figs. 12a, b, 13a, b).

The use of this technique in combination with ble-

pharoplasty, along with the effects that were achieved by

previous methods, made it possible to smooth out groove

Fig. 17 a, b, c, d, e, f Patient E: 46-year-old, before, 1 year and 5 years after midface correction with Aptos Needle 2G

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Fig. 18 a, b, c, d, e, f, g, h Patient H: 39-year-old, before, 1 year, 5 years and 8.5 years after midface correction with Aptos Needle 2G

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Fig. 19 The patient did not like the too prominent bucco-zygomatic areas, so 25 days after Aptos Needle 2G, the threads were removed

Fig. 20 The inflection of one of the Aptos Needle 2G needles was

performed too close to the dermis and caused retraction of the skin,

which was straightened by means of intensive massage

Fig. 21 Aptos Thread 2G threads were inserted too superficially. The

visualization of the threads was eliminated by intensive massage

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under the cheekbone fat, since sutures were fixed to the

periosteum of the orbit margin throughout its entire length

(Figs. 14a–g, 15a–f).

Similar results were achieved by Aptos Needle 2G, but

less invasively, without incisions and only through skin

punctures (Figs. 16a–f, 17a–f, 18a–h).

The nearest postoperative period proceeded smoothly

(Figs. 14b, 15b, e, 24b). The usual phenomenon was

swelling and hypercorrection. Hemorrhages, skin retrac-

tions at the insertion and exit points, contour irregularities

of the skin, pronounced asymmetry, and inflammatory

processes were rare. They were corrected along with the

skin contraction and the distribution of soft tissues under

the new conditions independently, by massage or admin-

istration of resorptive therapy and antibiotics. In rare cases,

it was necessary to remove the threads (Figs. 19, 20, 21,

22, 23, 24a).

Conclusions

Our APTOS methods for lifting the midface soft tissues

make it possible to achieve a new aesthetic harmony

quickly, easily, accurately, reliably, with minor surgical

trauma, with smooth contours of the skin surface, without

skin retraction and do not require excessively careful

postoperative management of patients. Another advantage

is the possibility of combination with classical methods of

lifting; moreover, classical methods can be performed in a

more truncated, less traumatic way without damaging the

result.

The described operations and manipulations, despite the

seeming simplicity, require a good qualification of a spe-

cialist, knowledge of the anatomy of the middle zone of the

face, a correct understanding of not only the aesthetics of

the face, but also of the patient’s desires.

Fig. 22 Pronounced edema and bruises

Fig. 23 Inflammatory processes after thread lifting

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Compliance with Ethical Standards

Conflict of interest The authors declare that they have no conflicts of

interest to disclose.

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Fig. 24 a, b, c Patient F: 33-year-old, before, right after the implantation of Aptos Thread 2G (there is no retraction of the derma in the

projection of the zygomatic arch, nor in the area of the nasolabial fold) and after 6 months

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