The mainstay of neck rejuvenation has relied on conventional surgical procedures. In recent years, other non-invasive options have replaced these techniques. One of these developments is the use of suspension threads, starting around 15 years ago utilising barbed sutures, then in the last decade with the use of non-absorbable coned sutures. More recently, a fully absorbable self-anchoring suture system (Silhouette Soft) has provided a useful technique in correcting mid-face and jaw-line laxity, and is currently licensed for use in brow and neck procedures.
An understanding of the features of the ageing neck is essential in application of the appropriate technique. The following aspects should be considered:
- Reduction in skin quality – loss of elasticity; skin redundancy
- Redistribution of fat – submental fat deposition; lateral atrophy of subcutaneous fat layer
- Role of platysma muscle – muscle laxity; platysmal bands
- Interaction with adjacent anatomical areas – lower face/jawline, décolletage.
Silhouette Soft sutures
Silhouette Soft sutures comprise a 3/0 suture of poly-L lactic acid mounted with cones consisting composite poly-L lactic acid/glycolic acid (approximately 4:1 ratio). Engagement of the cones within the subcutaneous tissues provides an immediate mechanical lifting / tightening due to soft tissue repositioning. The maintenance of this effect depends on slow release of lactic acid creating delayed biostimulation of collagen prolonging the duration of action (secondary anchoring system). In practical terms, the duration of effect is typically 9 to 12 months for the first procedure, but may last up to 18 months in subsequent repeat procedures.
The primary indication of Silhouette Soft is soft tissue laxity in the desired treatment area. Some volume loss (or more accurately, volume displacement) can be corrected.
The product is licensed for use in adults, but typically is utilised in individuals with ageing skin over the age of 40. In addition to the medical exclusions, there are two major categories considered unsuitable for the procedure: 1) hypertrophic tissues – excessive tissue density and thickness with maldistribution of subcutaneous fat; 2) atrophic tissues – due to low BMI or advanced age.
Practical aspects of Silhouette neck tightening
Thread suture patterns
Two techniques are currently used for neck procedures: 1) transverse U-16; 2) Reins technique: posterior straight 16x2. The latter is a newer development still undergoing evaluation. In this article, the more commonly used transverse U technique will be discussed.
After confirming the indications, the following issues should be discussed:
- Consenting – material risks and alternatives (as a result of the Montgomery Supreme Court Case).
- Aligning treatment outcome with client expectations.
- Duration of effect. Be realistic and do not overestimate.
- Cost. Whilst this is considered an advanced non-invasive procedure, the cost should be balanced with the outcome versus the cost.
- Expected and unexpected complications. It is important to brief clients on any potential complications, and in particular, material risks. You must be available to deal with concerns or complications. Consider reporting adverse events Medicines & Healthcare Products Regulatory Agency (MHRA) requirement.
- Adjunctive therapies. Anecdotal reports of enhanced effect following use of energy therapies such as radiofrequency (RF) or ultrasound (ultherapy, HIFU).
Planning the procedure
This entails the availability of a suitable environment – most aesthetic clinics will have a suitably equipped treatment room or dental office. Due consideration should be given to minimising contamination of the treated area by adopting good infection prevention principles National Institute of Health & Care Excellence (NICE). The timing of the procedure should be discussed, accounting for possible down-time afterwards, although this is usually not a major concern.
Accurate marking which dictates placement of the sutures is key to achieving good results. Figure 1 illustrates the important landmarks and traction vectors. The length of suture track may be greater than 12cm and should appreciate the 2cm or more of tightening to minimise cone loss. Recreation of the cervicomental angle is the priority for the upper suture limb – the exit points are placed at the angle anteriorly intersecting the midline. The exit points are placed in the thicker submastoid neck skin – firstly to provide good anchorage, and secondly to achieve optimal cosmetic outcome by hiding the entry points behind the hair.
The plane of suture insertion is typically the subcutaneous tissue. However, if the skin is of good quality and thickness, then a more superficial placement within platysma may be considered. Superficial placement should be avoided when the skin (and platysma) are thin due to the risk of visible cones, which may result in painful inflammatory nodules.
Local anaesthesia serves two purposes: 1) minimise discomfort during suture placement; 2) minimise bleeding and bruising.
Suture tightening should be performed in accordance with the recommended technique. Over-tightening may result in excessive skin ruffling with overtension on the cones causing subsequent loss of effect.
Aftercare advice should be rigorously followed. Rotation of the neck beyond 45 degrees should be avoided for the first two weeks to minimise loss of cone traction.
Disclaimer: Whilst detailed aspects of performing a Silhouette Soft procedure are outlined, this should not be used as a basis for performing the procedure without proper training and mentoring. (Contact Sinclair Pharma www.sinclairpharma.com for further details.) In advising clients regarding any procedure, the physician has a professional responsibility to discuss risks, benefits and alternatives.
Declaration of competing interests: Ian Morgan is a trainer for Silhouette Soft and also on the Medical Advisory Board, and receives remuneration for those activities. Some of the views expressed in the article are personal views and do not necessarily reflect the varied opinions of other users or trainers. Sinclair Pharma has approved the publication of this article in principle but has exerted no influence over the content.
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