[34] Gubisch W, Kotzur A. Our experience with silicone in rhinomentoplasty. Aesthetic

[35] Snyder GB, Courtiss EH, Kaye BM, Gradinger GP.A new chin implant for microgenia.

[36] Schoenrock LD, Chernoff WG. Subcutaneous implantation of Gore-Tex for facial

[37] Lewis RP, Schweitzer J, Odum BC, Lara WC, Edlich RF, Gampper TJ. Sheets, 3-D strands, trimensional (3-D) shapes, and sutures of either reinforced or nonreinforced expanded polytetrafluoroethylene for facial soft-tissue suspension, augmentation, and

[38] Singh S, Baker JL Jr. Use of expanded polytetrafluoroethylene in aesthetic surgery of the

[39] Gross EJ, Hamilton MM, Ackermann K, Perkins SW. Mersilene mesh chin augmentation. A 14-year experience. Arch Facial Plast Surg 1999 Jul-Sep;1(3):183-9

[21] Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg 86: 53-61, 1990. [22] Hamra ST. Composite rhytidectomy. Plast Reconstr Surg 90:1-13, 1992.

Plast Surg 1:5-9, 1984

Surg 28: 218-232, 1992.

America 1(2): 197-216, 1993.

Surg 2002 Feb;109(2):783-7

Craniofac Surg 2000 Nov;11(6):543-6

Plast Surg 1998 Jul-Aug;22(4):237-44

Plast Reconstr Surg 1978 Jun;61(6):854-61

face. Clin Plast Surg 2000 Oct;27(4):579-93

1999;15(1):3-12

Otolaryngol Head Neck Surg 115: 228-34, 1989.

Cosm Beauty Surg IJACBS 2001, 3 (1), 42-66

Presentations, Int J Cosm Surg, 2003, 3:3, 1-36

Tissue, Original Papers, Int J Cosm Surg, 2002, 2:1, 1-10

implants. J Oral Maxillofac Surg. 1998 May;56(5):549-52

to the lower face. Plast Reconstr Surg 2000 Jul;106(1):176-89

reconstruction. Otolaryngol Clin North Am 1995 Apr;28(2):325-40

reconstruction. J Long Term Eff Med Implants 1998;8(1):19-42

[1] Serdev, N.P. Year 1994, Suture Suspensions For Lifting Or Volume Augmentation In Face And Body (English version), presented at the 2nd Annual Meeing of the National Bulgarian Society for Aesthetic Surgery and Aesthetic Medicine, Sofia, 18 March 1994,

[2] Serdev NP. Serdev Suture Techniques Lower SMAS Face Lift, Original Papers, Int J

[3] Serdev NP.Ambulatory temporal SMAS lift using minimal hidden incisions. IJACBS,

[4] Serdev NP. Serdev Suture Techniques Lower SMAS Face Lift (Bulgarian), Original

[5] Serdev NP. SERDEV SUTURE TECHNIQUES - Lower SMAS Face LIFT, Original

[6] Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid

[8] Larabee WF, Makielski KH, Cupp C. Facelift anatomy. Facial Plastic Surgery Clinics of

[9] Brennan HG. Rhytidectomy: Mandibular and submandibular contouring. Facial Plastic

[10] Kridell RWH, Covello LV. The aging face (rhytidectomy). In BJ Bailey (ed.): Head & Neck Surgery – Otolaryngology, 2nd edition. Lippincott – Raven, 1998, pp. 2693-716. [11] Berman WE. Rhytidectomy. In CJ Krause (ed.) Aesthetic Facial Surgery. Lippincott,

[12] Dedo DD. The aging neck. In BJ Bailey (ed.): Head & Neck Surgery – Otolaryngology,

[13] Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy. Anatomical

[14] Seckel BR. Facial Danger Zones: Avoiding Nerve Injury in Facial Plastic Surgery.

[15] Webster RC, Smith RC, Papsidero MJ, et al. Comparison of SMAS plication with SMAS

[16] Lewis JR. Multiple-tiered deep support of cheeks in meloplasty and rhytidectomy.

[17] Owsley JQ. SMAS-platysma facelift. A bidirectional cervicofacial rhytidectomy. Clin

[7] Jost G, Lamouche G. SMAS in rhytidectomy. Aesthetic Plast Surg 2: 69-74, 1982

**Author details**

*New Bulgarian University, Sofia, Bulgaria*

Int J Aesth Cosm, 2001,1:1, 2561-2568

Papers, Int J Cosm Surg, 2009, 9:4, 1-12

Papers, Int J Cosm Surg, 2010, 10:1, 1-2

North America 1(2): 135-52, 1993.

and cheek area. Plast Reconstr Surg 58: 80-88, 1976.

Surgery Clinics of North America 1(2): 181-96, 1993.

2nd edition. Lippincott – Raven, 1998, pp. 2717-32.

Quality Medical Publishing, St. Louis, 1994.

Aesthetic Plast Surg 1: 21-5, 1983

Plast Surg 3: 429-401, 1983

variations and pitfalls. Plast Reconstr Surg 6: 781-95, 1979

imbrication in face lifting. Laryngoscope 92: 901-12, 1982.

Cosm Surg, 2009, 9:4, 1 - 2

1(2):17-24, 2001.

1991, pp 513-31.

Nikolay Serdev

**6. References**

	- [40] Sclaroff A, Williams C. Augmentation genioplasty: when bone is not enough. Am J Otolaryngol 1992 Mar-Apr;13(2):105-8

**Chapter 4**

© 2013 Serdev, licensee InTech. This is an open access chapter distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

© 2013 Serdev, licensee InTech. This is a paper distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**Serdev Sutures® Lifts in Body Areas**

Excisional body lift operations are traumatic surgical procedures that result in significant

The scarless transcutaneous closed approach Serdev Suture® method in buttock lift, breast lift, abdominal flaccidity lift was first presented in 1994 as a scarless alternative to the classic excision lifts, such as circumscisional body lifts, mammoplasty, abdominoplasty (tummy tuck) and others as part of the total understanding for the scarless closed approach suture lifting method. The concept is to lift stable mobile fascias to immobile tissues such as periosteum, immobile fascia, or tendons. This is achieved by a closed approach suture lift, using special instruments – curved semi-elastic Serdev® needles and semi-elastic surgical

The Serdev Suture® buttock lift presents a scarless surgical procedure for the treatment of the flaccid, flat and "unhappy buttock" form by a closed approach, without any requirement for incision and excision scars. The outcome is a visual change in buttock projection, roundness, tightness and elevation into a higher position. The buttock lift elongates the lower limbs and changes the proportions of the body. The aim is to obtain a beautification of the buttock form by creating a circumferential lifting effect on the buttock's subcutaneous tissue without scars. This is obtained by the use of a suture that takes hold of the inferiorly positioned deep fibrous tissue, elevating and fixing it to the "sacro-cutaneous" fascia (discovered by the author). This fascia fixes the overlying skin to the lateral lines of the

In scarless suture breast lift, the mobile breast glandular tissue and its fascia are lifted and fixed to the stable immobile anterior clavicle periosteum, or to the insertion of the pectoralis

The Serdev Suture® method allows for an atraumatic and scarless lift of the inner thigh

sutures, distinguished by an extended period of delayed absorption (2-3 years).

Additional information is available at the end of the chapter

sacrum and suspends the weight of the buttocks.

dermis to the tendon insertion of the gracilis muscle.

major tendon to humerus.

Nikolay Serdev

**1. Introduction**

scarring.

http://dx.doi.org/10.5772/55672

## **Serdev Sutures® Lifts in Body Areas**

Nikolay Serdev

126 Miniinvasive Face and Body Lifts – Closed Suture Lifts or Barbed Thread Lifts

recommendations. Angle Orthod 1977 Jul;47(3):173-85

Plast Reconstr Surg 1997 Oct;100(5):1336-53

implants. Facial Plast Surg 2000;16(1):35-44

Australas Coll Dent Surg 1998 Oct; 14:114-8

Otolaryngol 1992 Mar-Apr;13(2):105-8

1998;8(1):55-67

1998;8(1):3-17

Feb;27(2):116-8

[40] Sclaroff A, Williams C. Augmentation genioplasty: when bone is not enough. Am J

[41] Kheir JN, Leslie LF, Fulmer NL, Edlich RF, Gampper TJ. Polydimethylsiloxane for augmentation of the chin, malar, and nasal bones. J Long Term Eff Med Implants

[42] Yaremchuk MJ. Mandibular augmentation. Plast Reconstr Surg 2000 Sep;106(3):697-706 [43] Odum BC, Bussard GM, Lewis RP, Lara WC, Edlich RF, Gampper TJ. High-density porous polyethylene for facial bone augmentation. J Long Term Eff Med Implants

[44] Dann JJ, Epker BN. Proplast genioplasty: a retrospective study with treatment

[45] Qian Y, Fan Z, Yang Q. Application of MEDPOR surgical implant in the craniofacial reconstruction Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 1998 Mar;12(2):71-3 [46] Jafar M, Younger RA. Screw fixation mentoplasty. J Otolaryngol 2000 Oct;29(5):274-8 [47] Rubin JP, Yaremchuk MJ. Complications and toxicities of implantable biomaterials used in facial reconstructive and aesthetic surgery: a comprehensive review of the literature.

[48] Robinson M, Shuken R. Bone resorption under plastic chin implants. J Oral Surg 1969

[49] Maas CS, Merwin GE, Wilson J, Frey MD, Maves MD. Comparison of biomaterials for facial bone augmentation. 1: Arch Otolaryngol Head Neck Surg 1990 May;116(5):551-6 [50] Sclafani AP, Romo T 3rd. Collagen, human collagen, and fat: the search for a three-

[51] Constantinides MS, Galli SK, Miller PJ, Adamson PA. Malar, submalar, and midfacial

[52] Moenning JE, Wolford LM. Chin augmentation with various alloplastic materials: a

[53] Romo T 3rd, Baskin JZ, Sclafani AP. Augmentation of the cheeks, chin and pre-jowl

[54] Jones RH. The effects of zygomatic and chin augmentation on facial aesthetics. Ann R

comparative study. Int J Adult Orthodon Orthognath Surg 1989;4(3):175-87

dimensional soft tissue filler. Facial Plast Surg 2001 Feb;17(1):79-85

sulcus, and nasolabial folds. Facial Plast Surg 2001 Feb;17(1):67-78

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/55672

## **1. Introduction**

Excisional body lift operations are traumatic surgical procedures that result in significant scarring.

The scarless transcutaneous closed approach Serdev Suture® method in buttock lift, breast lift, abdominal flaccidity lift was first presented in 1994 as a scarless alternative to the classic excision lifts, such as circumscisional body lifts, mammoplasty, abdominoplasty (tummy tuck) and others as part of the total understanding for the scarless closed approach suture lifting method. The concept is to lift stable mobile fascias to immobile tissues such as periosteum, immobile fascia, or tendons. This is achieved by a closed approach suture lift, using special instruments – curved semi-elastic Serdev® needles and semi-elastic surgical sutures, distinguished by an extended period of delayed absorption (2-3 years).

The Serdev Suture® buttock lift presents a scarless surgical procedure for the treatment of the flaccid, flat and "unhappy buttock" form by a closed approach, without any requirement for incision and excision scars. The outcome is a visual change in buttock projection, roundness, tightness and elevation into a higher position. The buttock lift elongates the lower limbs and changes the proportions of the body. The aim is to obtain a beautification of the buttock form by creating a circumferential lifting effect on the buttock's subcutaneous tissue without scars. This is obtained by the use of a suture that takes hold of the inferiorly positioned deep fibrous tissue, elevating and fixing it to the "sacro-cutaneous" fascia (discovered by the author). This fascia fixes the overlying skin to the lateral lines of the sacrum and suspends the weight of the buttocks.

In scarless suture breast lift, the mobile breast glandular tissue and its fascia are lifted and fixed to the stable immobile anterior clavicle periosteum, or to the insertion of the pectoralis major tendon to humerus.

The Serdev Suture® method allows for an atraumatic and scarless lift of the inner thigh dermis to the tendon insertion of the gracilis muscle.

© 2013 Serdev, licensee InTech. This is an open access chapter distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 Serdev, licensee InTech. This is a paper distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The Serdev Suture® lift can be used in selected cases of thin patients to obtain a scarless and atraumatic tightening of the abdominal skin. This suture method for abdominal flaccidity lift is achieved by a closed approach suture as well, with skin perforations alone in the abdominal skin to capture, suture and lift the mobile superficial fascias supporting the abdominal skin. To obtain outcome longevity it is important to lift and stretch the firm mobile fascias, fixing them to immobile firm tissue, such as costal periosteum and/or perichondrium, periosteum of spina iliaca superior anterior.

Serdev Sutures®

The only immobile structure to which the suture can be fixed, in order to produce buttock lifting and secure the buttock weight, is the Serdev "sacro-cutaneous" fascia (discovered by the author) which fixes the skin to the lateral edges of the sacrum, located between the "dimples of Venus" at the sacro-iliac points and the upper point of the intra-gluteal fold, located at the sacro-coccigeal point. **NB!** Sacro-coccigeal fascia is not useful for fixation. Any attempt to attach the buttocks weight to the sacro-coccigeal fascia can provoke an

The gluteal fatty tissue is very fibrotic. The fibrotic tissue represents a flexible support for the soft framework of the body. It forms a stable network for subdermal and deep fat layers. We use this stable fibrotic buttock soft tissue structure in order to elevate it securely by

A. B.

**Figure 2.** The Serdev "sacro-cutaneous" fascia fixes the skin to lateral edges of the sacrum in the lower part of the "rhombus of Michaelis". It is located on each side, between the "dimples of Venus" and the upper point of the intra-gluteal fold, i.e. between the sacro-iliac points and the sacro-coccigeal point.

**Figure 1. A.** "Unhappy", sagging, loose buttock soft tissue, drooping between the thighs, engenders disappointment in women, inclining them to request buttock lifting. **B.** "Happy buttocks" - the outcomes

of lifting the hanging buttocks are visually elongated legs and more aesthetic body proportions.

"ischiadic" pain.

fixation to the Serdev fascia on each side.

Lifts in Body Areas 129

A stable improvement was observed in all patients. In the post-operative period, the complication rate was minimal and below 0.1%. All early comlications were resolved in the first 4-5 post-operative days. All other professional duties, social activities or obligations were possible in the next one or two days. These outpatient procedures are effective in the correction of laxity and ptosis. They also create a new form, along with improved body proportions that has been universally accepted as beautification beside rejuvenation.

## **2. Buttock lift**

As more people seek body contour surgery, we should use our expanding knowledge and surgical experience to create new, non-scarring surgical procedures for beautification in areas like the buttocks. Former results of body contour surgery have been less than satisfying. A very small number of techniques are available for correction of the form and aesthetics of the buttocks. This is especially so for lax, ptotic and non-projected buttocks. Scarless methods are preferred and demanded by virtually all patients.

Classic methods are combinations of liposuction, lipoinjections, implants for augmentation and lipectomy. The outpatient buttock lift procedure by suture can satisfy patients' requirements for beautification of the buttock form and position without scars and foreign bodies. The post-operative period is both rapid and easily tolerated, while the outcome is durable and long lasting.

## **2.1. Anatomy**

The well accepted gluteal position is the location of the gluteus maximus muscle. The muscle-sceletal framework is usually well formed. Unfortunately, female structure usually includes an inferiorly positioned fatty tissue deposit, elongating the female buttocks in the inferior perspective. Long and hanging buttocks are visible even from a frontal view (Fig. 1) and shorten the length of female lower limbs. The hanging buttocks soft tissue is well recognised as "unhappy buttocks" as distinct from the high gluteal position, known as "happy buttocks".

## **2.2. FIXATION of mobile to immobile tissue**

The only useful mobile tissue for suture lift is the very fibrotic buttocks soft tissue. **NB!**  Gluteus muscles and gluteus fascia cannot be lifted.

The only immobile structure to which the suture can be fixed, in order to produce buttock lifting and secure the buttock weight, is the Serdev "sacro-cutaneous" fascia (discovered by the author) which fixes the skin to the lateral edges of the sacrum, located between the "dimples of Venus" at the sacro-iliac points and the upper point of the intra-gluteal fold, located at the sacro-coccigeal point. **NB!** Sacro-coccigeal fascia is not useful for fixation. Any attempt to attach the buttocks weight to the sacro-coccigeal fascia can provoke an "ischiadic" pain.

The gluteal fatty tissue is very fibrotic. The fibrotic tissue represents a flexible support for the soft framework of the body. It forms a stable network for subdermal and deep fat layers. We use this stable fibrotic buttock soft tissue structure in order to elevate it securely by fixation to the Serdev fascia on each side.

128 Miniinvasive Face and Body Lifts – Closed Suture Lifts or Barbed Thread Lifts

perichondrium, periosteum of spina iliaca superior anterior.

**2. Buttock lift**

durable and long lasting.

**2.1. Anatomy**

"happy buttocks".

**2.2. FIXATION of mobile to immobile tissue**

Gluteus muscles and gluteus fascia cannot be lifted.

The Serdev Suture® lift can be used in selected cases of thin patients to obtain a scarless and atraumatic tightening of the abdominal skin. This suture method for abdominal flaccidity lift is achieved by a closed approach suture as well, with skin perforations alone in the abdominal skin to capture, suture and lift the mobile superficial fascias supporting the abdominal skin. To obtain outcome longevity it is important to lift and stretch the firm mobile fascias, fixing them to immobile firm tissue, such as costal periosteum and/or

A stable improvement was observed in all patients. In the post-operative period, the complication rate was minimal and below 0.1%. All early comlications were resolved in the first 4-5 post-operative days. All other professional duties, social activities or obligations were possible in the next one or two days. These outpatient procedures are effective in the correction of laxity and ptosis. They also create a new form, along with improved body

As more people seek body contour surgery, we should use our expanding knowledge and surgical experience to create new, non-scarring surgical procedures for beautification in areas like the buttocks. Former results of body contour surgery have been less than satisfying. A very small number of techniques are available for correction of the form and aesthetics of the buttocks. This is especially so for lax, ptotic and non-projected buttocks.

Classic methods are combinations of liposuction, lipoinjections, implants for augmentation and lipectomy. The outpatient buttock lift procedure by suture can satisfy patients' requirements for beautification of the buttock form and position without scars and foreign bodies. The post-operative period is both rapid and easily tolerated, while the outcome is

The well accepted gluteal position is the location of the gluteus maximus muscle. The muscle-sceletal framework is usually well formed. Unfortunately, female structure usually includes an inferiorly positioned fatty tissue deposit, elongating the female buttocks in the inferior perspective. Long and hanging buttocks are visible even from a frontal view (Fig. 1) and shorten the length of female lower limbs. The hanging buttocks soft tissue is well recognised as "unhappy buttocks" as distinct from the high gluteal position, known as

The only useful mobile tissue for suture lift is the very fibrotic buttocks soft tissue. **NB!**

proportions that has been universally accepted as beautification beside rejuvenation.

Scarless methods are preferred and demanded by virtually all patients.

A. B.

**Figure 1. A.** "Unhappy", sagging, loose buttock soft tissue, drooping between the thighs, engenders disappointment in women, inclining them to request buttock lifting. **B.** "Happy buttocks" - the outcomes of lifting the hanging buttocks are visually elongated legs and more aesthetic body proportions.

**Figure 2.** The Serdev "sacro-cutaneous" fascia fixes the skin to lateral edges of the sacrum in the lower part of the "rhombus of Michaelis". It is located on each side, between the "dimples of Venus" and the upper point of the intra-gluteal fold, i.e. between the sacro-iliac points and the sacro-coccigeal point.

## **2.3. Method**

**Indications:** Beautification, aesthetic proportions, lifting of ptosis, elongation of the lower limbs, shortening of the body length in proportion to the legs.

Serdev Sutures®

B. **Figure 3.** "Serdev fascia" is marked in red color. It is perpendicular to skin and sacrum and the suture with buttocks' heaviness will hang on it. Arrows show the direction of needle passes. A minimum of three passes is necessary to complete the fixation of the buttock fibrotic soft tissue system to Serdev fascia, which realizes a lift, roundness, projection and stable fixation of the mobile lower buttock to the

A. The first pass is from A to B1, then the direction of the needle is changed toward B, but higher than the anus (B1 is only an orientation, not a skin perforation point). The suture is introduced into A-B. Then, the needle is introduced in the second pass (C-B), in order to be threaded at B. Next, the second end of the suture is taken at A and fulfills the circle of the suture at C (third pass – C-A) to be tightened and knotted on Serdev fascia. If no dermis is attached to the suture, all dimples at the perforation points

B. Sometimes it is easier for beginners to perform 2 passes at once - to start from B to C and introduce the suture from C in direction to B, then change the direction of the needle tip towards A, without exiting the superficial fascia at B. This maneuver prevents beginners from dimpling at point B. After introducing the suture in lines C-B-A, the third pass C-A introduces the thread in line A-C and fulfils the suture circle at point C. The suture will be tightened and knotted at C. Dimpling at a perforation

The author prefers the first step for fixation of the subdermal fibrotic tissue to be initiated from the lateral aspect of the buttock. Selection of the type of surgical suture is the surgeon's responsibility. However, the elastic tightening of the Polycon suture provides a stable support with a short elasticity, when lifting the buttock into a higher position and fixing it to the stable sacro-cutaneous fascia. The suture collects the buttock's fibroic tissue and its trabecular system into a superficially convex "bouquet". This roundness is moved superiorly and fixed to the Serdev sacro-cutaneous fascia. The fixation of the suture to the stable inelastic fascia maximally ensures the longevity of the aesthetic effect. The semi-elastic quality of the antimicrobial polycaproamide suture Polycon (as preferred by the author) reduces the possibility of trauma and decubiti of the fibrotic tissue and reduces

immobile Serdev fascia. 2 methods are presented:

are easy to remove.

point has to be removed.

complications.

Lifts in Body Areas 131

The primary indication for buttock lift surgery by suture is the moderate to severe softtissue laxity in the lower trunk, with minimal or mild residual fat deposits. In patients with significant fat deposits, the author initially treats with UAL/VASER to reduce the volume and heaviness of the buttock fat tissue. Then, the reduced weight of the buttocks soft tissue can be lifted and fixed to the Serdev fascia in order to ensure a safe post-operative healing process.

The buttock lift by suture was created for aesthetic purposes, with the intention of creating a higher and more attractively rounded and projected buttocks, while at the same time creating a visible elongation of the legs and a change of the correlation between the body and the length of the lower limbs. True buttock sculpting demands a three-dimensional artistic appreciation of the anatomic and surgical adipose layers of the central trunk. This is essential in preventing complications from the buttock lifting, where the fixation is done without damaging neurovascular structures.

## **2.4. The technique**

Author's surgical technique consists of a fixation of the complete buttock soft tissue fibrotic system to the Serdev sacro-cutaneous fascia on each side. The suture technique uses the specially designed Serdev® needles from 170 mm to 250 mm, and Polycon USP 4, 6 or 8, depending on the degree of tissue volume and heaviness.

limbs, shortening of the body length in proportion to the legs.

without damaging neurovascular structures.

depending on the degree of tissue volume and heaviness.

**Indications:** Beautification, aesthetic proportions, lifting of ptosis, elongation of the lower

The primary indication for buttock lift surgery by suture is the moderate to severe softtissue laxity in the lower trunk, with minimal or mild residual fat deposits. In patients with significant fat deposits, the author initially treats with UAL/VASER to reduce the volume and heaviness of the buttock fat tissue. Then, the reduced weight of the buttocks soft tissue can be lifted and fixed to the Serdev fascia in order to ensure a safe post-operative healing

The buttock lift by suture was created for aesthetic purposes, with the intention of creating a higher and more attractively rounded and projected buttocks, while at the same time creating a visible elongation of the legs and a change of the correlation between the body and the length of the lower limbs. True buttock sculpting demands a three-dimensional artistic appreciation of the anatomic and surgical adipose layers of the central trunk. This is essential in preventing complications from the buttock lifting, where the fixation is done

Author's surgical technique consists of a fixation of the complete buttock soft tissue fibrotic system to the Serdev sacro-cutaneous fascia on each side. The suture technique uses the specially designed Serdev® needles from 170 mm to 250 mm, and Polycon USP 4, 6 or 8,

A.

**2.3. Method**

process.

**2.4. The technique**

B.

**Figure 3.** "Serdev fascia" is marked in red color. It is perpendicular to skin and sacrum and the suture with buttocks' heaviness will hang on it. Arrows show the direction of needle passes. A minimum of three passes is necessary to complete the fixation of the buttock fibrotic soft tissue system to Serdev fascia, which realizes a lift, roundness, projection and stable fixation of the mobile lower buttock to the immobile Serdev fascia. 2 methods are presented:

A. The first pass is from A to B1, then the direction of the needle is changed toward B, but higher than the anus (B1 is only an orientation, not a skin perforation point). The suture is introduced into A-B. Then, the needle is introduced in the second pass (C-B), in order to be threaded at B. Next, the second end of the suture is taken at A and fulfills the circle of the suture at C (third pass – C-A) to be tightened and knotted on Serdev fascia. If no dermis is attached to the suture, all dimples at the perforation points are easy to remove.

B. Sometimes it is easier for beginners to perform 2 passes at once - to start from B to C and introduce the suture from C in direction to B, then change the direction of the needle tip towards A, without exiting the superficial fascia at B. This maneuver prevents beginners from dimpling at point B. After introducing the suture in lines C-B-A, the third pass C-A introduces the thread in line A-C and fulfils the suture circle at point C. The suture will be tightened and knotted at C. Dimpling at a perforation point has to be removed.

The author prefers the first step for fixation of the subdermal fibrotic tissue to be initiated from the lateral aspect of the buttock. Selection of the type of surgical suture is the surgeon's responsibility. However, the elastic tightening of the Polycon suture provides a stable support with a short elasticity, when lifting the buttock into a higher position and fixing it to the stable sacro-cutaneous fascia. The suture collects the buttock's fibroic tissue and its trabecular system into a superficially convex "bouquet". This roundness is moved superiorly and fixed to the Serdev sacro-cutaneous fascia. The fixation of the suture to the stable inelastic fascia maximally ensures the longevity of the aesthetic effect. The semi-elastic quality of the antimicrobial polycaproamide suture Polycon (as preferred by the author) reduces the possibility of trauma and decubiti of the fibrotic tissue and reduces complications.

The buttock lift by suture requires 10 to 15 minutes of operating time per side, no blood transfusions, no stay at the clinic, no nursing care and no more than a day or two absence from work.

Serdev Sutures®

**2.7. Technique**

**Variant A (Fig. 3. A)**

from dimple formation).

doctors prefer to knot at C.

at C. Remove dimpling.

fascia medially.

Video: http://www.youtube.com/watch?v=mn0O2bNkG7o

fold (see Fig. 3) in order to stretch and flatten it when the buttock is lifted:

First Pass - A-B: It should be deep in the soft tissue, 2 fingers higher than the infragluteal

Tie the suture as closely as possible to medium tension. In this way, the whole buttock tissue will be collected and projected like a "bouquet" by the suture and fixed higher to the Serdev

fascia. Pull out all dimpling at points A, B and C, using a mosquito clamp.

Lifts in Body Areas 133

## **2.5. Directions**

Mark skin perforation points A, B and C (B1 should be only marked, not perforated, it is an orientation point). Point A should be located laterally, at the midpoint of each buttock, near the place where the trochanter can be palpated. This ensures equal distance to points B and C.

## **2.6. Tips and tricks**

After anesthetic infiltration intradermally and deep in points A, (B1), B and C, and deep in the soft tissue along the marked suture circle, make small perforation at points A, B and C. Then, open the perforations and deep subdermal fat in perpendicular fashion with a mosquito clamp. Take sterile needle caps from 18-guage needle, cut part of the closed needle cap tip. Insert these plastic cannulas in twisting perpendicular fashion, maximum deep into perforation points A, B and C, in order for the suture to stay deep in the fat fibrotic tissue (near but above the gluteus fascia) and away from dermis and subdermal fibrotic tissue. This maneuver prevents dimpling.

## **2.7. Technique**

132 Miniinvasive Face and Body Lifts – Closed Suture Lifts or Barbed Thread Lifts

from work.

and C.

**2.5. Directions**

**2.6. Tips and tricks**

contamination.

will produce dimpling.

pain and should be avoided!

This maneuver prevents dimpling.

and will not permit longevity of the lift.

suspended on it.

not permit lifting.

The buttock lift by suture requires 10 to 15 minutes of operating time per side, no blood transfusions, no stay at the clinic, no nursing care and no more than a day or two absence

Mark skin perforation points A, B and C (B1 should be only marked, not perforated, it is an orientation point). Point A should be located laterally, at the midpoint of each buttock, near the place where the trochanter can be palpated. This ensures equal distance to points B

After anesthetic infiltration intradermally and deep in points A, (B1), B and C, and deep in the soft tissue along the marked suture circle, make small perforation at points A, B and C. Then, open the perforations and deep subdermal fat in perpendicular fashion with a mosquito clamp. Take sterile needle caps from 18-guage needle, cut part of the closed needle cap tip. Insert these plastic cannulas in twisting perpendicular fashion, maximum deep into perforation points A, B and C, in order for the suture to stay deep in the fat fibrotic tissue (near but above the gluteus fascia) and away from dermis and subdermal fibrotic tissue.

B1, the needle direction should be changed to B as shown in Fig. 3.A.

Video: http://www.youtube.com/watch?v=mn0O2bNkG7o

First Pass - A-B: It should be deep in the soft tissue, 2 fingers higher than the infragluteal fold (see Fig. 3) in order to stretch and flatten it when the buttock is lifted:

#### **Variant A (Fig. 3. A)**

	- **Pass A-C:** Load the needle at point A. From A, proceed to C deep subdermally (without superficial dimpling), and cross laterally through the upper part of Serdev fascia. Perforate the Serdev fascia near the upper pole and exit at point C through the plastic hub. Unload the needle at C and pull back the empty needle through point A. The suture circle is finalized and both ends of the suture are located at C. Remove cannulae, tighten and knot. Remove dimpling at perforation points. **NB!** If you want to tie the knot at point A, proceed with empty needle from A to C and load needle at C. Introduce the suture at C-A. Then you will have both ends at A. Tightening and knotting the suture at A is somehow difficult for beginners. Most doctors prefer to knot at C.
	- **If pass C-A is selected:** From C, proceed to A, load the needle at A and unload it at C. Both ends of the suture will be located at C. Remove cannulas, tighten and knot at C. Remove dimpling.

Tie the suture as closely as possible to medium tension. In this way, the whole buttock tissue will be collected and projected like a "bouquet" by the suture and fixed higher to the Serdev fascia. Pull out all dimpling at points A, B and C, using a mosquito clamp.

**NB!** Do not perform suture triangles ABC. The higher pressure in the angles will cut the tissue and the suture will become loose. The circle of the suture should be round to apply equal pressure at each point and minimize trauma of the tissue.

Serdev Sutures®

In all his cases, the author has observed only one patient with a painful hardness in point B, near the infra-gluteal fold and four other cases with a local infection in one of the wounds. The cause for the first complication was the rigid nylon suture that was used in this first patient. Rigidity, hardness and inelasticity caused a tissue decubitus in the point of tension on the soft tissue. This complication has since then been avoided by changing the suture material to the semi-elastic Bulgarian antimicrobial Polycon suture. In all other cases, the local infection was easily treated in a matter of days. Infections are very rare, occurring mainly at the skin perforation points and are easily treated. No hematoma or nerve damage have been observed. Pain is limited to the first 1-2 weeks in sitting position. In limited cases, when the pain goes away, patients forget the advices to gradually commence physical activities. In these few cases, abnormal friction and trauma can cause pain that is usually on one side. Palpation along the suture gives information about presence or absence of

In very rare cases, the skin perforation point was opened and some seroma or blood drops have been evacuated with the disappearance of the pain. If there is no infiltration around the suture, slowing down activities, non-steroid anti-inflammatory drugs and pain killers are

A. B.

infiltration and location of the pain. It is usually near a perforation point.

enough. Antibiotic can be added if considered necessary.

author.

**2.13. Clinical cases**

Lifts in Body Areas 135

The close proximity of the wounds to the anus area makes antibiotic prophylaxis and strict hygiene obligatory.

## **2.8. Warnings**

## **2.9. Author's experience**

More than a thousand buttock lifts have been performed by the author in the last 19 years, both in his clinic and during live surgery workshops around the world. Patients ranged in age from 18 to 62 years. The author reports his experience with patients followed up for up to 10 years.

## **2.10. Combined methods**

63% of the patients had moderate lower trunk and lower limb cellulite and fat deposits, which required additional ultrasonic liposculpture of the lower body and limbs. In patients who have had buttock lift in combination with ultrasonic assisted liposculpture, UAL was performed to reduce the volume and to sculpture the buttocks and other areas for total leg or body beautification. Additional positive qualities of UAL are skin tightening and weight loss. When using UAL for buttock sculpturing, the goal is to minimize fat deposits, buttock's weight and to obtain a nicely rounded and higher positioned buttocks (over the gluteus maximus muscle).

#### **2.11. Results**

The buttock lift by suture requires 10 to 15 minutes of operating time per side, there is no blood loss or transfusions, no stay at the clinic, no nursing care and not more than a day or two absence from work.

The cosmetic results were evaluated with pre-operative and post-operative photographs and by patient satisfaction. No patient was dissatisfied with the results and all of them considered their results as excellent or very good.

## **2.12. Risks and complications**

Risks are: higher pressure on one tissue being different from the tension in other areas and points; contamination - skin perforation point B near the anus area.

In all his cases, the author has observed only one patient with a painful hardness in point B, near the infra-gluteal fold and four other cases with a local infection in one of the wounds. The cause for the first complication was the rigid nylon suture that was used in this first patient. Rigidity, hardness and inelasticity caused a tissue decubitus in the point of tension on the soft tissue. This complication has since then been avoided by changing the suture material to the semi-elastic Bulgarian antimicrobial Polycon suture. In all other cases, the local infection was easily treated in a matter of days. Infections are very rare, occurring mainly at the skin perforation points and are easily treated. No hematoma or nerve damage have been observed. Pain is limited to the first 1-2 weeks in sitting position. In limited cases, when the pain goes away, patients forget the advices to gradually commence physical activities. In these few cases, abnormal friction and trauma can cause pain that is usually on one side. Palpation along the suture gives information about presence or absence of infiltration and location of the pain. It is usually near a perforation point.

In very rare cases, the skin perforation point was opened and some seroma or blood drops have been evacuated with the disappearance of the pain. If there is no infiltration around the suture, slowing down activities, non-steroid anti-inflammatory drugs and pain killers are enough. Antibiotic can be added if considered necessary.

## **2.13. Clinical cases**

134 Miniinvasive Face and Body Lifts – Closed Suture Lifts or Barbed Thread Lifts

hygiene obligatory.

ischiadic pain.

**2.9. Author's experience**

**2.10. Combined methods**

maximus muscle).

two absence from work.

**2.12. Risks and complications**

considered their results as excellent or very good.

points; contamination - skin perforation point B near the anus area.

**2.11. Results**

**2.8. Warnings**

equal pressure at each point and minimize trauma of the tissue.

1. Do not perforate gluteal fascia or muscle. They cannot be lifted.

**NB!** Do not perform suture triangles ABC. The higher pressure in the angles will cut the tissue and the suture will become loose. The circle of the suture should be round to apply

The close proximity of the wounds to the anus area makes antibiotic prophylaxis and strict

2. Do not perforate the sacrococcigeal fascia or periosteum at point C – this causes

3. Make a circular suture to obtain equal pressure around all points.  Patients ranged in age from 18 to 62 years. The author reports his experience with patients followed up for up to 10 years.

63% of the patients had moderate lower trunk and lower limb cellulite and fat deposits, which required additional ultrasonic liposculpture of the lower body and limbs. In patients who have had buttock lift in combination with ultrasonic assisted liposculpture, UAL was performed to reduce the volume and to sculpture the buttocks and other areas for total leg or body beautification. Additional positive qualities of UAL are skin tightening and weight loss. When using UAL for buttock sculpturing, the goal is to minimize fat deposits, buttock's weight and to obtain a nicely rounded and higher positioned buttocks (over the gluteus

The buttock lift by suture requires 10 to 15 minutes of operating time per side, there is no blood loss or transfusions, no stay at the clinic, no nursing care and not more than a day or

The cosmetic results were evaluated with pre-operative and post-operative photographs and by patient satisfaction. No patient was dissatisfied with the results and all of them

Risks are: higher pressure on one tissue being different from the tension in other areas and

triangle sutures - tension on the angles will cut the tissue and produce pain.

Serdev Sutures®

A. B.

**Figure 6. A.** Before, **B.** Result after a buttock lift by suture. Elongation of the legs. Better projection and

A. B.

**Figure 7. A.** Before and **B.** After buttock lift by Serdev Suture®. Visible elongation of the lower

extremities and shortening of the trunk after buttock lift.

higher buttocks.

Lifts in Body Areas 137

**Figure 4. A., C.** Before UAL and Buttock lift. **B., D.** Day one after ultrasonic liposculpturing of lower extremities, buttocks and flanks and simultaneous Buttock lift by Serdev Suture®. Pre-operative drawings are still visible. Very rare bruising verifies that surgery has been atraumatic. Tight, higher buttocks, straight and elongated legs, correct proportions.

**Figure 5. A.** Before, **B.** Result after a buttock lift by suture in a dancer. Elongation of the legs. Better projection and higher buttocks are visible even in anterior half-profile position. No incision scars.

buttocks, straight and elongated legs, correct proportions.

C. D.

A. B.

**Figure 5. A.** Before, **B.** Result after a buttock lift by suture in a dancer. Elongation of the legs. Better projection and higher buttocks are visible even in anterior half-profile position. No incision scars.

**Figure 4. A., C.** Before UAL and Buttock lift. **B., D.** Day one after ultrasonic liposculpturing of lower extremities, buttocks and flanks and simultaneous Buttock lift by Serdev Suture®. Pre-operative drawings are still visible. Very rare bruising verifies that surgery has been atraumatic. Tight, higher

**Figure 6. A.** Before, **B.** Result after a buttock lift by suture. Elongation of the legs. Better projection and higher buttocks.

**Figure 7. A.** Before and **B.** After buttock lift by Serdev Suture®. Visible elongation of the lower extremities and shortening of the trunk after buttock lift.

Serdev Sutures®

There is an increasing demand for surgical correction of the body contour in modern society. There is a limited number of operations that aim to correct non-aesthetic buttocks form as part of the total body contouring and proportions. The hips, thighs and the lower back frame the buttock contours. Ethnic differences in the shape and proportions of the buttocks create a variety of aesthetic perceptions in size and shape. However, high positioned "happy" buttocks and elongated legs have always been

Flat and sagging buttocks are a common clinical condition. However, before the introduction of the suture butt lift, there was no proven aesthetic and effective therapeutic option at hand. Sole excision of skin cannot obtain a true lift of the heavy buttocks. Subcision is a surgical technique that has been used in treating advanced degree of cellulite. To treat excesses of fat and skin tissue in that area, liposuction and/or dermolipectomy have been mostly used. The indication for liposuction has been restricted to the conditions in which the overlying skin is capable to retract and adapt itself to the new contour. If excess skin is the cause of the deformity, a dermolipectomy has been

Liposuction of the buttock area is infrequently mentioned in the literature and for some authors it is a forbidden zone. Two additional approaches in suction lipectomy of the buttock region are described: liposuction of the "banana" and liposuction of the "sensuous triangle". A common complication of liposuction of this area is ptosis of the buttocks. To improve buttock roundness, fat transplantation and different implants, including mammary ones, have been introduced. These procedures do not lift, but only augment buttocks. Free fat graft has been used to avoid the most common complications of doing a buttock augmentation with silicone prostheses and to find a better surgical procedure that is simpler, complementary with liposuction while better able to deal with body irregularities. Lately, excessive augmentations can be observed in Brazil and Latin America, which are not acceptable in Caucasian communities, where aesthetic

Furthermore, the suture lift is the best option for Afro-Americans and Asians, where there is

**2.15. Buttock augmentation, wrongly named "lifting"**

**2.14. Discussion**

fashionable.

mostly indicated.

proportions are important.

**3.1. Clavicular fixation**

**3. Breast lift**

a tendency to hypertrophic scarring.

Video: http://www.youtube.com/watch?v=bHKA5HaiZs0

Lifts in Body Areas 139

**Figure 8. A., C.** Before, **B., D.** Result after buttock lift by suture in a 62 y.o. patient. The buttocks are visibly lifted and a better-rounded form is obtained. There is improvement of the whole body shape.

#### **2.14. Discussion**

138 Miniinvasive Face and Body Lifts – Closed Suture Lifts or Barbed Thread Lifts

A. B.

C. D.

**Figure 8. A., C.** Before, **B., D.** Result after buttock lift by suture in a 62 y.o. patient. The buttocks are visibly lifted and a better-rounded form is obtained. There is improvement of the whole body shape. There is an increasing demand for surgical correction of the body contour in modern society. There is a limited number of operations that aim to correct non-aesthetic buttocks form as part of the total body contouring and proportions. The hips, thighs and the lower back frame the buttock contours. Ethnic differences in the shape and proportions of the buttocks create a variety of aesthetic perceptions in size and shape. However, high positioned "happy" buttocks and elongated legs have always been fashionable.

 However, before the introduction of the suture butt lift, there was no proven aesthetic and effective therapeutic option at hand. Sole excision of skin cannot obtain a true lift of the heavy buttocks. Subcision is a surgical technique that has been used in treating advanced degree of cellulite. To treat excesses of fat and skin tissue in that area, liposuction and/or dermolipectomy have been mostly used. The indication for liposuction has been restricted to the conditions in which the overlying skin is capable to retract and adapt itself to the new contour. If excess skin is the cause of the deformity, a dermolipectomy has been mostly indicated.

### **2.15. Buttock augmentation, wrongly named "lifting"**

Liposuction of the buttock area is infrequently mentioned in the literature and for some authors it is a forbidden zone. Two additional approaches in suction lipectomy of the buttock region are described: liposuction of the "banana" and liposuction of the "sensuous triangle". A common complication of liposuction of this area is ptosis of the buttocks. To improve buttock roundness, fat transplantation and different implants, including mammary ones, have been introduced. These procedures do not lift, but only augment buttocks. Free fat graft has been used to avoid the most common complications of doing a buttock augmentation with silicone prostheses and to find a better surgical procedure that is simpler, complementary with liposuction while better able to deal with body irregularities. Lately, excessive augmentations can be observed in Brazil and Latin America, which are not acceptable in Caucasian communities, where aesthetic proportions are important.

Furthermore, the suture lift is the best option for Afro-Americans and Asians, where there is a tendency to hypertrophic scarring.

#### **3. Breast lift**

#### **3.1. Clavicular fixation**

Video: http://www.youtube.com/watch?v=bHKA5HaiZs0

Serdev Sutures®

Place a plastic tape measure around the neck directed to the nipples and mark the lines.

If requirements for more central or more lateral nipple position, select a more central or

**c)** Local anesthesia in points A, A1, subperiosteally in A-A1, intradermally in point B and perpendicularly into the breast fascia, upper breast tissue and below, on the A-B line in deep

**d)** Perforate points A, A1 and B using a No. 11 scalpel blade. Perforate the blunt subdermal fascia in points A, A1 and the breast glandular tissue fascia in point B using mosquito

**Warning: If not perforated, the superficial fascias will be engaged in the suture, forming**

Pass an unloaded "mini mini" (50 mm) or "mini" (60 mm) Serdev® needle from point A to A1 under the anterior clavicle periosteum. Load the needle with a USP 4 or 6 surgical suture (depending on breast size) and introduce it under the anterior clavicle periosteum A-A1.

**Warning: Do not pass dorsal to the clavicle (danger: subclavian a. and v., brachial plexus) f)** Take the upper breast glandular fascia and tissue at point B, using "medium" (140 mm) Serdev® needle. Proceed to point A1 in the deep subdermal fat. Feed the suture end into the

**Warning: Unwanted superficial needle pass forms dimpling on the skin surface. Try**

**Stay above the pectoralis fascia. If engaged, the pectoralis fascia will block the needle and**

**g)** Proceed with the needle from point A in deep subdermal tissue and then over the breast tissue to point B. Feed the second suture end into the needle from point B passing it into

**Warning: Do not perforate through dermis at the skin perforations, as this will result in a dimple. In the skin perforation points, pass the needle perpendicularly to the skin surface, without catching dermis (without resistance in front), by gently twisting the**

**h)** Tie at point A. Check for equality. After securing the knot, release any dimpling at points

Measure and mark the distance "nipple to clavicle" on both sides.

Medial or Lateral – for medial or lateral nipple position

Serdev® needle at point A1 and introduce it toward B.

point A to accomplish the circle of the suture.

A, A1 and B with a hemostat.

**again a deeper pass to obtain a smooth surface over the needle.**

**the suture and then it will produce immobility of the suture.**

**needle. Do not push - twist the needle gently forwards or backwards.**

more lateral clavicular fixation point.

**a dimpling effect on the surface**

**e)** Clavicular Fixaction A-A1:

Central position

subdermal fat layer.

clamp.

Lifts in Body Areas 141

**Figure 9. А.** Before breast lift to clavicle and to pectoralis tendon. **B.** Result – 14 cm lift of the nipple

NOTES:

#### DIRECTIONS:

**a)** Mark the borders of the breast glandular tissue. Select the breast fixation point B depending on the breast heaviness in the upper part of the glandular tissue.

**b)** Select the position for the clavicular fixation. It could be:

#### Central position

140 Miniinvasive Face and Body Lifts – Closed Suture Lifts or Barbed Thread Lifts

A B

**a)** Mark the borders of the breast glandular tissue. Select the breast fixation point B

**Figure 9. А.** Before breast lift to clavicle and to pectoralis tendon. **B.** Result – 14 cm lift of the nipple

Take anterior clavicular periosteum and never posterior.

for additional support to clavicular fixation in larger breasts.

**b)** Select the position for the clavicular fixation. It could be:

depending on the breast heaviness in the upper part of the glandular tissue.

NOTES:

DIRECTIONS:

Place a plastic tape measure around the neck directed to the nipples and mark the lines. Measure and mark the distance "nipple to clavicle" on both sides.

#### Medial or Lateral – for medial or lateral nipple position

If requirements for more central or more lateral nipple position, select a more central or more lateral clavicular fixation point.

**c)** Local anesthesia in points A, A1, subperiosteally in A-A1, intradermally in point B and perpendicularly into the breast fascia, upper breast tissue and below, on the A-B line in deep subdermal fat layer.

**d)** Perforate points A, A1 and B using a No. 11 scalpel blade. Perforate the blunt subdermal fascia in points A, A1 and the breast glandular tissue fascia in point B using mosquito clamp.

#### **Warning: If not perforated, the superficial fascias will be engaged in the suture, forming a dimpling effect on the surface**

**e)** Clavicular Fixaction A-A1:

Pass an unloaded "mini mini" (50 mm) or "mini" (60 mm) Serdev® needle from point A to A1 under the anterior clavicle periosteum. Load the needle with a USP 4 or 6 surgical suture (depending on breast size) and introduce it under the anterior clavicle periosteum A-A1.

#### **Warning: Do not pass dorsal to the clavicle (danger: subclavian a. and v., brachial plexus)**

**f)** Take the upper breast glandular fascia and tissue at point B, using "medium" (140 mm) Serdev® needle. Proceed to point A1 in the deep subdermal fat. Feed the suture end into the Serdev® needle at point A1 and introduce it toward B.

**Warning: Unwanted superficial needle pass forms dimpling on the skin surface. Try again a deeper pass to obtain a smooth surface over the needle.**

#### **Stay above the pectoralis fascia. If engaged, the pectoralis fascia will block the needle and the suture and then it will produce immobility of the suture.**

**g)** Proceed with the needle from point A in deep subdermal tissue and then over the breast tissue to point B. Feed the second suture end into the needle from point B passing it into point A to accomplish the circle of the suture.

**Warning: Do not perforate through dermis at the skin perforations, as this will result in a dimple. In the skin perforation points, pass the needle perpendicularly to the skin surface, without catching dermis (without resistance in front), by gently twisting the needle. Do not push - twist the needle gently forwards or backwards.**

**h)** Tie at point A. Check for equality. After securing the knot, release any dimpling at points A, A1 and B with a hemostat.

**Warning: Serdev Sutures® should not engage skin. Skin cannot hold or support the suspended tissue.**

Serdev Sutures®

**c)** Perforate points A and B, using a No. 11 scalpel blade. Perforate the subdermal fascia and

**Warning: If not perforated, the fascias will be engaged in the suture, forming a dimpling**

**d)** Using an unloaded "medium" (140 mm) Serdev® needle, pass from point A, through pectoralis major tendon to A1. Point A1 can be a skin perforation or not. If no skin perforation point A1 is selected, change the needle direction, passing deep in the subdermal fat layer. then under the upper breast tissue, then perpendicular up through breast tissue and skin perforation at point B. Thread needle with USP 4, or 6 suture. Pull through point A. **Note: If easier, perforate A1 and introduce a threaded "mini" or "mini mini" Serdev® needle in line A-A1. Then, using an unloaded "medium" needle proceed from point B through the upper breast fascia, upper breast tissue, and in the deep subdermal fat to**

**e)** With the unloaded needle, take a different plane in the subdermal fat in line A-B, exiting at point B **(do not grab the tendon and the glandular breast fascia with the second pass, but stay in deep subdermal fat tissue)** Load needle at point B and pull through at point A. **f)** While pulling both suture ends at point A, release any dimpling seen at point A1 and B. Tie with medium tension at point A. After tying and securing the knot, release any dimpling

breast fascia bluntly in point B, using a mosquito clamp.

**point A1. Next, thread the needle at A1 and pull it through at point B.**

**effect on the surface.**

with a hemostat at **point A, A1 and B.**

Lifts in Body Areas 143

**Figure 10. A.** Before**, B.** After a 14 cm breast lift by clavicular suture in large ptotic breasts. A second "step-by-step" breast lift by suture can be performed after months.

**Figure 11.** Breast lift by suture to the clavicle in a young patient.

## **3.2. Pectoralis tendon fixation**

#### DIRECTIONS:

**a)** Select the place of fixation to the pectoralis major tendon at its insertion to the axilla - Point A.

**Note: In point A, the needle pass through the tendon should start from the dorsal side of the tendon to the front of it - Point A1. In other words - Point A should be posterior to the pectoralis tendon, near its insertion to the brachium.**

**b)** Local anesthesia in point A1, through the tendon to Point A, intradermally in point B and perpendicularly into the breast fascia, upper breast tissue and below, and in the deep subdermal fat layer on the A-A1-B line.

**c)** Perforate points A and B, using a No. 11 scalpel blade. Perforate the subdermal fascia and breast fascia bluntly in point B, using a mosquito clamp.

142 Miniinvasive Face and Body Lifts – Closed Suture Lifts or Barbed Thread Lifts

"step-by-step" breast lift by suture can be performed after months.

**Figure 11.** Breast lift by suture to the clavicle in a young patient.

**pectoralis tendon, near its insertion to the brachium.**

subdermal fat layer on the A-A1-B line.

**3.2. Pectoralis tendon fixation**

DIRECTIONS:

Point A.

**suspended tissue.**

**Warning: Serdev Sutures® should not engage skin. Skin cannot hold or support the**

A B

A B

**a)** Select the place of fixation to the pectoralis major tendon at its insertion to the axilla -

**Note: In point A, the needle pass through the tendon should start from the dorsal side of the tendon to the front of it - Point A1. In other words - Point A should be posterior to the**

**b)** Local anesthesia in point A1, through the tendon to Point A, intradermally in point B and perpendicularly into the breast fascia, upper breast tissue and below, and in the deep

**Figure 10. A.** Before**, B.** After a 14 cm breast lift by clavicular suture in large ptotic breasts. A second

#### **Warning: If not perforated, the fascias will be engaged in the suture, forming a dimpling effect on the surface.**

**d)** Using an unloaded "medium" (140 mm) Serdev® needle, pass from point A, through pectoralis major tendon to A1. Point A1 can be a skin perforation or not. If no skin perforation point A1 is selected, change the needle direction, passing deep in the subdermal fat layer. then under the upper breast tissue, then perpendicular up through breast tissue and skin perforation at point B. Thread needle with USP 4, or 6 suture. Pull through point A.

**Note: If easier, perforate A1 and introduce a threaded "mini" or "mini mini" Serdev® needle in line A-A1. Then, using an unloaded "medium" needle proceed from point B through the upper breast fascia, upper breast tissue, and in the deep subdermal fat to point A1. Next, thread the needle at A1 and pull it through at point B.**

**e)** With the unloaded needle, take a different plane in the subdermal fat in line A-B, exiting at point B **(do not grab the tendon and the glandular breast fascia with the second pass, but stay in deep subdermal fat tissue)** Load needle at point B and pull through at point A.

**f)** While pulling both suture ends at point A, release any dimpling seen at point A1 and B. Tie with medium tension at point A. After tying and securing the knot, release any dimpling with a hemostat at **point A, A1 and B.**

Serdev Sutures®

Position the patient so that the upper inner thigh is exposed (leg externally rotated). In this position the Gracilis muscle is the only visibly prominent muscle and tendon under the skin of the upper inner thigh. To identify the Gracilis tendon, palpate along the Gracilis muscle.

Administer local anaesthetic injection to the dermis to be sutured (exactly over the upper fat

Make a stab incision with a No. 11 blade into the free-from-fat skin (in the lowest point

Perforate skin opening **A** with the Serdev® needle (mini-mini, or mini), elevate the skin with the needle to the Gracilis tendon insertion and securely pass through the tendon insertion. Lift the skin perforation on the other side to the level of the needle tip (needle is fixed in the tendon). Pass the needle through opening **B**. Load a USP 2 Bulgarian (Polycon) suture into the needle eye at point B and retrogradely withdraw the needle through point **A**. With this pass, the suture is fixed to the immobile Gracilis Tendon insertion. Allow the skin to relax back to its original position. Now make the second pass precisely through the firm dermis from **A** to **B** (very difficult – gently twisting forward (not pushing) the Serdev® needle) and passing through the skin opening at point **B**. Now load the free end of the suture into the eye of the needle. Retrogradely withdraw the needle from point **B** through the dermis pass and point **A**. With this pass, the movable firm dermis is attached to the suture and the circle

Tie a secure surgical knot under medium elastic tension. Cut the suture just short of the knot and let it dive into the opening. At this point is very important to release the skin at points

The Gracilis tendon will be located immediately below the Pubic Tubercle.

possible) on both sides of the Gracilis Tendon. Incisions will be 1-1.5cm apart.

border), surrounding soft tissues and in the proximal Gracilis tendon.

of the suture is finalized with the 2 free suture ends at point **A**.

**A** and **B** with a mosquito clamp to remove any dimpling of the skin.

**Figure 13.** Inner thigh lift by suture is fixed to the incertion of the gracilis tendon

this area and will disappear in 2-4 weeks.

The medial thigh will now be lifted and the inner thigh skin will be stretched.

Skin folding will be placed high in the fold, laterally from the major labia. The initial skin folding due to skin lifting, anesthesia and swelling will adapt to the very wrinkled skin in

Lifts in Body Areas 145

**Figure 12.** Before and after a breast lift with fixation to the pectoralis tendon. After subpectoral implants placement, the patient has given two births and after breast-feeding the breasts have dropped. Breast lift by suture solves the problem without additional surgery for bigger implant placement or excisional mastopexy.

## **4. Inner thigh lift**

#### **4.1. Introduction**

Excisional thigh and buttock operations are traumatic surgical procedures that result in significant scarring. The Serdev Suture® method allows for an atraumatic and scarless lift of the inner thigh.

#### **4.2. Anatomy**

Inner thigh fat is attached to skin that loosens with time and descends with age, obesity and weight loss.

Between the major labia and the inner thigh fat deposit, there is about 3-5 cm skin that is free from any attached fat. The length of the fat-free skin depends on age, fat weight and skin laxity.

#### **4.3. Surgical concept**

The Serdev Suture® method is a stable suture fixation of movable to non-movable fibrous structures. The use of semi-elastic, absorbable surgical sutures is crucial, as they do not cut the target mobile tissue and when fibrosis is finalized (6 to 18 months) the sutures will be absorbed (in 2-3 years).

## **4.4. The procedure**

The Dermis layer, precisely adjacent to the fat deposit, has to be sutured to the Gracilis tendon, near its insertion point at the Pubis (Fig. 13).

Position the patient so that the upper inner thigh is exposed (leg externally rotated). In this position the Gracilis muscle is the only visibly prominent muscle and tendon under the skin of the upper inner thigh. To identify the Gracilis tendon, palpate along the Gracilis muscle. The Gracilis tendon will be located immediately below the Pubic Tubercle.

144 Miniinvasive Face and Body Lifts – Closed Suture Lifts or Barbed Thread Lifts

excisional mastopexy.

**4. Inner thigh lift**

**4.1. Introduction**

the inner thigh.

**4.2. Anatomy**

weight loss.

skin laxity.

**4.3. Surgical concept**

absorbed (in 2-3 years).

**4.4. The procedure**

tendon, near its insertion point at the Pubis (Fig. 13).

**Figure 12.** Before and after a breast lift with fixation to the pectoralis tendon. After subpectoral implants placement, the patient has given two births and after breast-feeding the breasts have dropped. Breast lift by suture solves the problem without additional surgery for bigger implant placement or

Excisional thigh and buttock operations are traumatic surgical procedures that result in significant scarring. The Serdev Suture® method allows for an atraumatic and scarless lift of

Inner thigh fat is attached to skin that loosens with time and descends with age, obesity and

Between the major labia and the inner thigh fat deposit, there is about 3-5 cm skin that is free from any attached fat. The length of the fat-free skin depends on age, fat weight and

The Serdev Suture® method is a stable suture fixation of movable to non-movable fibrous structures. The use of semi-elastic, absorbable surgical sutures is crucial, as they do not cut the target mobile tissue and when fibrosis is finalized (6 to 18 months) the sutures will be

The Dermis layer, precisely adjacent to the fat deposit, has to be sutured to the Gracilis

Administer local anaesthetic injection to the dermis to be sutured (exactly over the upper fat border), surrounding soft tissues and in the proximal Gracilis tendon.

Make a stab incision with a No. 11 blade into the free-from-fat skin (in the lowest point possible) on both sides of the Gracilis Tendon. Incisions will be 1-1.5cm apart.

Perforate skin opening **A** with the Serdev® needle (mini-mini, or mini), elevate the skin with the needle to the Gracilis tendon insertion and securely pass through the tendon insertion. Lift the skin perforation on the other side to the level of the needle tip (needle is fixed in the tendon). Pass the needle through opening **B**. Load a USP 2 Bulgarian (Polycon) suture into the needle eye at point B and retrogradely withdraw the needle through point **A**. With this pass, the suture is fixed to the immobile Gracilis Tendon insertion. Allow the skin to relax back to its original position. Now make the second pass precisely through the firm dermis from **A** to **B** (very difficult – gently twisting forward (not pushing) the Serdev® needle) and passing through the skin opening at point **B**. Now load the free end of the suture into the eye of the needle. Retrogradely withdraw the needle from point **B** through the dermis pass and point **A**. With this pass, the movable firm dermis is attached to the suture and the circle of the suture is finalized with the 2 free suture ends at point **A**.

Tie a secure surgical knot under medium elastic tension. Cut the suture just short of the knot and let it dive into the opening. At this point is very important to release the skin at points **A** and **B** with a mosquito clamp to remove any dimpling of the skin.

**Figure 13.** Inner thigh lift by suture is fixed to the incertion of the gracilis tendon

The medial thigh will now be lifted and the inner thigh skin will be stretched.

Skin folding will be placed high in the fold, laterally from the major labia. The initial skin folding due to skin lifting, anesthesia and swelling will adapt to the very wrinkled skin in this area and will disappear in 2-4 weeks.

## **5. Abdominal flaccidity lift**

## **5.1. Introduction**

This suture method for abdominal flaccidity was first presented in 1994 as a scarless alternative to the classic abdominoplasty (tummy tuck) and a part of the total understanding for the scarless closed approach suture lifting method all over face and body. The concept is the lift of abdominal skin without engaging it in the suture. This is achieved by a closed approach suture lift, using special instruments – curved semi-elastic needles and semielastic surgical sutures, distinguished by an extended period of delayed absorption (2-3 years).

Serdev Sutures®

and along the length of linea alba, introduce the "medium" 140 mm Serdev® needle into point A, without capturing the dermis. In abdomen lifts the author uses a set of Serdev®

Take periosteum of the xiphoid and, by gently twisting the needle forward through the linea alba, exit at B. Load the needle and pull through. Second pass A-B is without catching periosteum. Load the second end of the suture and pull it through line B-A. The circle of the suture is fulfilled. Tie at A using medium elastic tension to lift the mobile linea alba in the direction of the xiphoid periosteum fixation. **NB!** Shortening of the linea alba length can be produced as well, without fixation to the periosteum, but only by shortening the lengths

**Figure 14.** The needle is fixed to the xiphoid periosteum at A. Then, with soft, twisting zigzag motions through the length of linea alba it exits through point B, without catching dermis. The tip is loaded and the thread will be pulled through the line B-A. The second A-B pass will be more superficial, without producing dimpling on the surface (dimpling indicates an overly superficial pass), in order to load the second suture end and pull it through. The knot will be tied at A. Both passes could be located at both

**2. Cephalic, lateral and distal lifting** - to stretch the flaccid abdominal skin in cephalic, lateral and distal direction is performed by a fixation of the mobile superficial fascia to

Mark point A at costal periosteum/perichondrium level, or at spina iliaca anterior superior. Check the flaccidity level and mark point B (medial to A) at a selected distance. After

needles with different lengths.

sides of the linea alba.

immobile structures, such as:

**5.3. Surgical procedure**

b) the spiina iliaca anterior superior

a) the costal line periosteum/perichondrium,

between 2 selected points of the linea alba, above the navel.

Lifts in Body Areas 147

The author uses skin perforations alone in the abdominal skin to capture, suture and lift the superficial fascias and linea alba supporting the abdominal skin. To obtain outcome longevity, it is important to lift and stretch these firm mobile fascias, fixing them to immobile firm tissue, such as xiphoid periosteum, costal and spina iliaca anterior superior periosteum.

The Serdev Suture® lift can be used in selected cases of thin patients to obtain a scarless and atraumatic tightening of the abdominal skin.

### **5.2. Anatomy**

Anatomy landmarks are linea alba, superficial fascia, bone periosteum around the abdomen.

Firm mobile fascias fixing the abdominal skin are linea alba and superficial fascia. Firm immobile structures utilized in turn for fixation of the mobile fascias are the xiphoid process, the costal line, spina iliaca anterior superior.

Linea alba runs from the xiphoid process to the pubic symphysis and is mostly composed of collagen connective tissue. It fixes the abdominal skin longitudinally to the mid-line and consisting only of connective tissue, does not contain important nerves or blood vessels.

The superficial fascia of the abdomen fixes the anterior abdominal skin by a trabecular system. The superficial fascia consists of one thicker fatty superficial layer (Camper's fascia). There is also a membranous deep layer (Scarpa's fascia). The superficial vessels and nerves run between these two layers. It is important to preserve the a.and v. epigastrica inf.

**The Procedure – see video** http://youtu.be/oXU\_80OqtOg

"sad navel", "sad abdomen" = flaccidity

The aim of the transcutaneous, scarless, closed approach Serdev Sutures® for abdominal flaccidity lift is:

**1. Cephalic lift** - to produce a "happy navel" when shortening the length of linea alba.

Two skin perforation points are used: Point A at the xiphoid and point B at a selected length of the linea alba in the upper abdomen. After anesthetic infiltration in the points A and B and along the length of linea alba, introduce the "medium" 140 mm Serdev® needle into point A, without capturing the dermis. In abdomen lifts the author uses a set of Serdev® needles with different lengths.

Take periosteum of the xiphoid and, by gently twisting the needle forward through the linea alba, exit at B. Load the needle and pull through. Second pass A-B is without catching periosteum. Load the second end of the suture and pull it through line B-A. The circle of the suture is fulfilled. Tie at A using medium elastic tension to lift the mobile linea alba in the direction of the xiphoid periosteum fixation. **NB!** Shortening of the linea alba length can be produced as well, without fixation to the periosteum, but only by shortening the lengths between 2 selected points of the linea alba, above the navel.

**Figure 14.** The needle is fixed to the xiphoid periosteum at A. Then, with soft, twisting zigzag motions through the length of linea alba it exits through point B, without catching dermis. The tip is loaded and the thread will be pulled through the line B-A. The second A-B pass will be more superficial, without producing dimpling on the surface (dimpling indicates an overly superficial pass), in order to load the second suture end and pull it through. The knot will be tied at A. Both passes could be located at both sides of the linea alba.

**2. Cephalic, lateral and distal lifting** - to stretch the flaccid abdominal skin in cephalic, lateral and distal direction is performed by a fixation of the mobile superficial fascia to immobile structures, such as:

#### **5.3. Surgical procedure**

146 Miniinvasive Face and Body Lifts – Closed Suture Lifts or Barbed Thread Lifts

This suture method for abdominal flaccidity was first presented in 1994 as a scarless alternative to the classic abdominoplasty (tummy tuck) and a part of the total understanding for the scarless closed approach suture lifting method all over face and body. The concept is the lift of abdominal skin without engaging it in the suture. This is achieved by a closed approach suture lift, using special instruments – curved semi-elastic needles and semielastic surgical sutures, distinguished by an extended period of delayed absorption (2-3

The author uses skin perforations alone in the abdominal skin to capture, suture and lift the superficial fascias and linea alba supporting the abdominal skin. To obtain outcome longevity, it is important to lift and stretch these firm mobile fascias, fixing them to immobile firm tissue, such as xiphoid periosteum, costal and spina iliaca anterior superior

The Serdev Suture® lift can be used in selected cases of thin patients to obtain a scarless and

Anatomy landmarks are linea alba, superficial fascia, bone periosteum around the abdomen. Firm mobile fascias fixing the abdominal skin are linea alba and superficial fascia. Firm immobile structures utilized in turn for fixation of the mobile fascias are the xiphoid

Linea alba runs from the xiphoid process to the pubic symphysis and is mostly composed of collagen connective tissue. It fixes the abdominal skin longitudinally to the mid-line and consisting only of connective tissue, does not contain important nerves or blood vessels.

The superficial fascia of the abdomen fixes the anterior abdominal skin by a trabecular system. The superficial fascia consists of one thicker fatty superficial layer (Camper's fascia). There is also a membranous deep layer (Scarpa's fascia). The superficial vessels and nerves

The aim of the transcutaneous, scarless, closed approach Serdev Sutures® for abdominal

Two skin perforation points are used: Point A at the xiphoid and point B at a selected length of the linea alba in the upper abdomen. After anesthetic infiltration in the points A and B

**1. Cephalic lift** - to produce a "happy navel" when shortening the length of linea alba.

run between these two layers. It is important to preserve the a.and v. epigastrica inf.

**5. Abdominal flaccidity lift**

atraumatic tightening of the abdominal skin.

process, the costal line, spina iliaca anterior superior.

**The Procedure – see video** http://youtu.be/oXU\_80OqtOg

"sad navel", "sad abdomen" = flaccidity

**5.1. Introduction**

years).

periosteum.

**5.2. Anatomy**

flaccidity lift is:

Mark point A at costal periosteum/perichondrium level, or at spina iliaca anterior superior. Check the flaccidity level and mark point B (medial to A) at a selected distance. After

anesthetic infiltration in points A and B and along the length of line A-B, introduce "medium" (140 mm), "small" (100 mm) or "mini" (60 mm) Serdev® needle into point A, without capturing the dermis. Take periosteum and proceed a little deeper to capture the superficial fascia and exit at B. **NB!** Be careful not to perforate through the anterior abdominal wall. Superficial fascia is just below the abdominal skin. Move the needle laterally to check fascia fixation. Load the needle and pull it through. The second pass A-B is more superficial, without catching superficial fascia or periosteum. Load the second end of the surgical suture and pull it through line B-A. The circle of the suture is fulfilled. Tie at point A, using medium elastic tension, to stretch the mobile superficial fascia in direction to the immobile periosteum, perichondrium or linea alba at A, which reflects in stretching of the attached abdominal skin.

Serdev Sutures®

C D

**Figure 15. A.** Before and immediately after linea alba lift, superficial fascia lift to costal periosteum and to spina iliaca anterior superior, **B.** Edema absorption after 20 days, **C.** before and **D.** final result. Bandages in the thorax area are connected with early post op secondary breast augmentation period.

**Buttock lifts**: Redundant tissue in sagging buttocks can be corrected by excision lifts. However, these are seldom used procedures because of post-operative problems, such as unacceptable inferiorly displacement, wide scars, early recurrence of ptosis, large trauma,

In order to limit these complications in flat and sagging buttocks without remarkable fat deposits, the author has developed a surgical technique, using a circumferential suture of the soft tissue to the sacro-cutaneous fascia discovered by the author. The circumferential suspension gives strong vertical support with minimal tension in each point and reduces the complications, which are traditionally associated with other procedures. The author's suture lift offers fewer complications than any others described. It is an efficient and safe procedure to correct or enhance buttock contour. It has virtually eliminated most complications of

In patients, whose problem was excessive fat in conjunction with flabbiness, UAL of the buttocks combined with the buttock suture lifting method completed the main goals of the procedure in one or more different stages. The combination of UAL and buttock lift by the suture technique described in this chapter is a minimally invasive procedure that can be

The Serdev Suture® buttock lifting technique is simple and low in cost, with minimal morbidity and very good results. It is important to note that a good result does not depend

Edema absorption in the fixation locations takes about a month.

blood loss and a prolonged post-operative period.

liposuction and dermolipectomies under general anaesthesia.

used to reduce and lift the buttocks at the same time.

**5.4. Conclusion**

Results are more than satisfactory. Selection of patients is important.

Lifts in Body Areas 149

A

**Figure 15. A.** Before and immediately after linea alba lift, superficial fascia lift to costal periosteum and to spina iliaca anterior superior, **B.** Edema absorption after 20 days, **C.** before and **D.** final result. Bandages in the thorax area are connected with early post op secondary breast augmentation period.

Edema absorption in the fixation locations takes about a month.

Results are more than satisfactory. Selection of patients is important.

### **5.4. Conclusion**

148 Miniinvasive Face and Body Lifts – Closed Suture Lifts or Barbed Thread Lifts

the attached abdominal skin.

anesthetic infiltration in points A and B and along the length of line A-B, introduce "medium" (140 mm), "small" (100 mm) or "mini" (60 mm) Serdev® needle into point A, without capturing the dermis. Take periosteum and proceed a little deeper to capture the superficial fascia and exit at B. **NB!** Be careful not to perforate through the anterior abdominal wall. Superficial fascia is just below the abdominal skin. Move the needle laterally to check fascia fixation. Load the needle and pull it through. The second pass A-B is more superficial, without catching superficial fascia or periosteum. Load the second end of the surgical suture and pull it through line B-A. The circle of the suture is fulfilled. Tie at point A, using medium elastic tension, to stretch the mobile superficial fascia in direction to the immobile periosteum, perichondrium or linea alba at A, which reflects in stretching of

A

B

**Buttock lifts**: Redundant tissue in sagging buttocks can be corrected by excision lifts. However, these are seldom used procedures because of post-operative problems, such as unacceptable inferiorly displacement, wide scars, early recurrence of ptosis, large trauma, blood loss and a prolonged post-operative period.

In order to limit these complications in flat and sagging buttocks without remarkable fat deposits, the author has developed a surgical technique, using a circumferential suture of the soft tissue to the sacro-cutaneous fascia discovered by the author. The circumferential suspension gives strong vertical support with minimal tension in each point and reduces the complications, which are traditionally associated with other procedures. The author's suture lift offers fewer complications than any others described. It is an efficient and safe procedure to correct or enhance buttock contour. It has virtually eliminated most complications of liposuction and dermolipectomies under general anaesthesia.

In patients, whose problem was excessive fat in conjunction with flabbiness, UAL of the buttocks combined with the buttock suture lifting method completed the main goals of the procedure in one or more different stages. The combination of UAL and buttock lift by the suture technique described in this chapter is a minimally invasive procedure that can be used to reduce and lift the buttocks at the same time.

The Serdev Suture® buttock lifting technique is simple and low in cost, with minimal morbidity and very good results. It is important to note that a good result does not depend on great surgery but rather on more simple and acceptable procedures for the patients. Outcomes incorporate harmonious structuring and positioning of the form, lifting of the lower portion of the buttocks, augmentation in the upper gluteus part and better projection. Complications with suture lift of the buttocks are few and patient satisfaction is high. The result is a visual change in the buttock projection, roundness, tightness and higher positioning. The buttock lift elongates the lower limbs and visibly changes the proportions of the body. Patients of regular weight seeking higher, rounded and projected buttocks with better proportions are indicated. Heavy buttocks and obesity are contraindicated.

Serdev Sutures®

[4] Serdev, NP. Buttocks lifting without implants - Serdev technique no visible scars" Aesthetic Surgery Course In Sofia, Bulgaria, Medical Center "Aesthetic Surgery,

[5] Anikina TI. Soft framework of the human body, Arkh Anat Gistol Embriol 1980

[6] Hexsel DM, Mazzuco R., Subcision: a treatment for cellulite. Int J Dermatol 2000

[7] Gargan TJ, Courtiss EH., The risks of suction lipectomy. Their prevention and

[8] Schlesinger SL. Two arcane areas in liposuction: the banana and the sensuous triangle.

[9] Gasparotti M. Superficial liposuction: a new application of the technique for aged and

[10] Pitanguy I. Surgical reduction of the abdomen, thigh, and buttocks. Surg Clin North

[11] Delerm A, Cirotteau Y. Cruro-femoro-gluteal or circumgluteal plasty. Ann Chir Plast

[12] Agris J. Use of dermal-fat suspension flaps for thigh and buttock lifts. Plast Reconstr

[13] Gasperoni C, Salgarello M. MALL liposuction: the natural evolution of subdermal

[14] Shaer WD. Gluteal and thigh reduction: reclassification, critical review, and improved

[15] Chajchir A., Fat injection: long-term follow-Up. Aesthetic Plast Surg 1996 Jul-

[16] Cardenas-Camarena L, Lacouture AM, Tobar-Losada A., Combined gluteoplasty:

[17] Lack EB. Contouring the female buttocks. Liposculpting the buttocks. Dermatol Clin

[19] Pereira LH, Radwanski HN., Fat grafting of the buttocks and lower limbs. Aesthetic

[20] Hanke CW, Bullock S, Bernstein G., Current status of tumescent liposuction in the

[21] De Pedroza LV., Fat transplantation to the buttocks and legs for aesthetic enhancement or correction of deformities: long-term results of large volumes of fat transplant.

[22] Teimourian B, Adham MN. Anterior periosteal dermal suspension with suction

[23] Guerrerosantos J. Secondary hip-buttock-thigh plasty. Clin Plast Surg 1984 Jul;11(3):491-

[24] Lockwood T. Lower body lift with superficial fascial system suspension. Plast Reconstr

superficial liposuction. Aesthetic Plast Surg 1994 Summer;18(3):253-7

technique for primary correction. Aesthetic Plast Surg 1984;8(3):165-72

liposuction and lipoinjection. Plast Reconstr Surg 1999 Oct;104(5):1524-31;

United States. National survey results. Dermatol Surg 1996 Jul;22(7):595-8

curettage for lateral thigh lipectomy. Aesthetic Plast Surg 1982;6(4):207-9

503Lewis JR Jr. Body contouring. South Med J 1980 Aug;73(8):1006-11

[18] Lewis JR Jr. Body contouring. South Med J 1980 Aug;73(8):1006-11

Aesthetic Medicine, November 26, 2001

treatment. Clin Plast Surg 1984 Jul;11(3):457-63

Aesthetic Plast Surg 1991 Spring;15(2):175-80

flaccid skin. Aesthetic Plast Surg 1992 Spring;16(2):141-53

Mar;78(3):5-15

Jul;39(7):539-44

1973;18(1):31-6

Aug;20(4):291-6

1999 Oct;17(4):815-22

Plast Surg 1996 Sep-Oct;20(5):409-16

Dermatol Surg 2000 Dec;26(12):1145-9

Surg 1993 Nov;92(6):1112-22

Am 1971 Apr;51(2):479-89

Surg 1977 Jun;59(6):817- 22

Lifts in Body Areas 151

**Breast Lifts:** Redundant tissue in ptotic and giant breasts can be corrected by excision lifts. However, these are procedures with wide scars, early recurrence of ptosis, large trauma, blood loss and a prolonged post-operative period, post-operative problems, such as unacceptable displacement etc.

The Serdev Suture® breast lifting technique is simple, with minimal morbidity and very good results. Complications with suture lift are few and patient satisfaction is high. The result is a visual change in the projection, tightness and higher positioning, as well as position of the nipple at the middle of the humerus. Heavy breasts and large ptosis are contraindicated.

**Inner Thigh lift** by suture is indicated mostly in skinny patients.

**Abdominal Flacidity**: Serdev Suture® for abdominal flaccidity lift is a satisfactory procedure that can be done in several steps. It is scarless and atraumatic. No complications have been observed. Selection of patients and their acceptance of a time interval for the adaptation of some bulging/edema in areas of fixation to the costal periosteum is crucial for patients' satisfaction. It is a good alternative to abdominoplasty in thin and selected patients.

## **Author details**

**Nikolay Serdev**

*New Bulgarian University, Sofia, Bulgaria*

## **6. References**

[4] Serdev, NP. Buttocks lifting without implants - Serdev technique no visible scars" Aesthetic Surgery Course In Sofia, Bulgaria, Medical Center "Aesthetic Surgery, Aesthetic Medicine, November 26, 2001

150 Miniinvasive Face and Body Lifts – Closed Suture Lifts or Barbed Thread Lifts

unacceptable displacement etc.

contraindicated.

**Author details**

*New Bulgarian University, Sofia, Bulgaria*

Int J Aesth Cosm, 2001,1:1, 2561-2568

**Nikolay Serdev**

**6. References**

on great surgery but rather on more simple and acceptable procedures for the patients. Outcomes incorporate harmonious structuring and positioning of the form, lifting of the lower portion of the buttocks, augmentation in the upper gluteus part and better projection. Complications with suture lift of the buttocks are few and patient satisfaction is high. The result is a visual change in the buttock projection, roundness, tightness and higher positioning. The buttock lift elongates the lower limbs and visibly changes the proportions of the body. Patients of regular weight seeking higher, rounded and projected buttocks with

**Breast Lifts:** Redundant tissue in ptotic and giant breasts can be corrected by excision lifts. However, these are procedures with wide scars, early recurrence of ptosis, large trauma, blood loss and a prolonged post-operative period, post-operative problems, such as

The Serdev Suture® breast lifting technique is simple, with minimal morbidity and very good results. Complications with suture lift are few and patient satisfaction is high. The result is a visual change in the projection, tightness and higher positioning, as well as position of the nipple at the middle of the humerus. Heavy breasts and large ptosis are

**Abdominal Flacidity**: Serdev Suture® for abdominal flaccidity lift is a satisfactory procedure that can be done in several steps. It is scarless and atraumatic. No complications have been observed. Selection of patients and their acceptance of a time interval for the adaptation of some bulging/edema in areas of fixation to the costal periosteum is crucial for patients'

[1] Serdev, N.P. Year 1994, Suture Suspensions For Lifting Or Volume Augmentation In Face And Body (English version), presented at the 2nd Annual Meeing of the National Bulgarian Society for Aesthetic Surgery and Aesthetic Medicine, Sofia, 18 March 1994,

[2] Serdev, NP. Buttock lift. Two own methods. 3rd International Congress of the South-American Academy of Cosmetic Surgery, Buenos Aires, Argentina, October 19-21, 2001 [3] Serdev, NP. Buttocks lift by ultrasonic assisted liposuction - My technique International Journal of Aesthetic Cosmetic Beauty Surgery Volume 1, Number 3, 1991, 130-54

satisfaction. It is a good alternative to abdominoplasty in thin and selected patients.

better proportions are indicated. Heavy buttocks and obesity are contraindicated.

**Inner Thigh lift** by suture is indicated mostly in skinny patients.

	- [25] Regnault P, Daniel R. Secondary thigh-buttock deformities after classical techniques. Prevention and treatment. Clin Plast Surg 1984 Jul;11(3):505-16

**Chapter 5**

© 2013 Des Fernandes, licensee InTech. This is an open access chapter distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2013 Des Fernandes, licensee InTech. This is a paper distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**Percutaneous Suspension Sutures**

Although a number of procedures have been described for placement of "shaping sutures" during open and closed rhinoplasty, scant attention is given to the possibility of percutaneous placement of sutures without dissection of the skin envelop. Periodically patients will present who want minimal changes to their nose because the tip is too bulky, not well defined and the nose is longer than ideal. Many of these patients have no concerns about the bridge width and do not have a dorsal hump. This is the perfect patient to

Many other patients have had an attractive straight nose when they were young and as they have aged, the nose has become coarser, broader and tends to lengthen and lose support from the septum and then droops into becoming a hooked nose. The operation that will be described specifically addresses these changes and with this surprisingly simple operation,

Other patients who have had a corrective rhinoplasty develop a typical "polly-beak" deformity. By elevating and rotating the nasal cartilages one can restore a normal nasal tip

**to Change the Nasal Tip**

Additional information is available at the end of the chapter

consider using the operation that will be described.

the nose can be restored to much closer to the original.

The following instruments and materials are required:

2. 18 gauge (green) needle or a 22 (yellow) spinal needle.

projection and a straight bridge.

1. 11 or 15 blade scalpel

3. Sharp pointed fine scissors 4. Fine dissector (optional)

**2. Methods and instruments**

M. B. Des Fernandes

http://dx.doi.org/10.5772/56249

**1. Introduction**

## **Percutaneous Suspension Sutures to Change the Nasal Tip**

M. B. Des Fernandes

152 Miniinvasive Face and Body Lifts – Closed Suture Lifts or Barbed Thread Lifts

Mar;38(3):213-6

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2002 Mar-Apr;26(2):126-9

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Surg 2002 May-Jun;26(3):223-30

Reparatrice Appar Mot 1994;80(3):188-95

Prevention and treatment. Clin Plast Surg 1984 Jul;11(3):505-16

buttocks pexy. Aesthetic Plast Surg 1997 Jul-Aug;21(4):245-53

techniques. Clin Biomech (Bristol, Avon) 1995 Apr;10(3):122-127

studies. Plast Reconstr Surg 1994 Sep;94(3):496-506

grafting. Aesthetic Plast Surg 2000 Nov-Dec;24(6):412-7

the Experts" - San Salvador, Int J Cosm Surg 2009, 9, 2, 1 – 39

Japanese. Ann Plast Surg 1980 Jul;5(1):31-9

and Medicine Int J Cosm Surg, 2010, 10, 3, 1 – 1

Surg 1997 Dec;23(12):1197-200

[25] Regnault P, Daniel R. Secondary thigh-buttock deformities after classical techniques.

[26] Gonzalez M, Guerrerosantos J. Deep planed torso-abdominoplasty combined with

[27] Carwell GR, Horton CE Sr. Circumferential torsoplasty. Ann Plast Surg 1997

[28] Heddens CJ. Belt lipectomy: procedure and outcomes. Plast Surg Nurs 2001

[29] Pascal JF, Le Louarn C. Remodeling bodylift with high lateral tension. Aesthetic Plast

[30] Lavigne P, Loriot de Rouvray TH. The superior gluteal nerve. Anatomical study of its extrapelvic portion and surgical resolution by trans-gluteal approach Rev Chir Orthop

[31] Karnes J, Salisbury M, Schaeferle M, Beckham P, Ersek RA. Hip lift. Aesthetic Plast Surg

[32] Hagen K, Sorhagen O, Harms-Ringdahl K., Influence of weight and frequency on thigh and lower-trunk motion during repetitive lifting employing stoop and squat

[33] Niechajev I, Sevcuk O., Long-term results of fat transplantation: clinical and histologic

[34] Guerrerosantos J., Autologous fat grafting for body contouring. Clin Plast Surg 1996

[35] Peren PA, Gomez JB, Guerrerosantos J, Salazar CA. Gluteus augmentation with fat

[36] Ichida M, Kamiishi H, Shioya N., Aesthetic surgery of the trunk and extremities in the

[37] Lawrence N, Coleman WP 3rd., The biologic basis of ultrasonic liposuction. Dermatol

[38] Serdev, N.P. Breast Lift: My Methods Presentations from the Congress "VI Sharing with

[39] Serdev, N.P. Serdev Suture Techniques Breast Lift Original Papers, Int J Cosm Surg,

[40] Serdev, N.P. Minimally Invasive Author Technique For Breast Lift Without Scars Using Sutures Abstracts - The First World Multidisciplinary Congress on Cosmetic Surgery

[41] Serdev, N.P. Tratamento De Flacides Cutanea Abdominal Com Filos Elasticos Serdev / Scarless Serdev Suture Methods For Abdominal Skin Flaccidity, 12 Congresso Brasiliero

Medicina Estetica - 15 - 18 June 2005, Salvador, Int J Cosm Surg, 2006, 6, 1, 1 - 25

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/56249

## **1. Introduction**

Although a number of procedures have been described for placement of "shaping sutures" during open and closed rhinoplasty, scant attention is given to the possibility of percutaneous placement of sutures without dissection of the skin envelop. Periodically patients will present who want minimal changes to their nose because the tip is too bulky, not well defined and the nose is longer than ideal. Many of these patients have no concerns about the bridge width and do not have a dorsal hump. This is the perfect patient to consider using the operation that will be described.

Many other patients have had an attractive straight nose when they were young and as they have aged, the nose has become coarser, broader and tends to lengthen and lose support from the septum and then droops into becoming a hooked nose. The operation that will be described specifically addresses these changes and with this surprisingly simple operation, the nose can be restored to much closer to the original.

Other patients who have had a corrective rhinoplasty develop a typical "polly-beak" deformity. By elevating and rotating the nasal cartilages one can restore a normal nasal tip projection and a straight bridge.

## **2. Methods and instruments**

The following instruments and materials are required:

© 2013 Des Fernandes, licensee InTech. This is an open access chapter distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 Des Fernandes, licensee InTech. This is a paper distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Percutaneous Suspension Sutures to Change the Nasal Tip 155

3. The line will traverse the soft triangle of the nostril as it courses towards the lowest part of the columella. Usually this is at the position where the columella changes angle

4. As one draws this line one has to take into account the shape of the lower lateral alar cartilages. (See Fig 2). Normally as seen from the front in figure 2, the line is straight

5. However, if the cartilages are bulging and wide then one should deviate the line laterally towards the maximum width as seen from the frontal view. (See Fig 3) Generally if one presses on the lateral alar wings one can determine where this essential point is to apply medial pressure in order to narrow the nose tip. Its worth spending

6. Then mark the midline of the columella with a vertical 3-4 mm line where the incision will be made. This incision is also dependant on where the columella will be lifted.

in the "ideal" nose.

**Figure 2.** Showing the skin markings for the standard nose

time familiarising yourself with these little details.

7. Similar markings are made on the opposite side.

downwards.

The procedure is usually done in an office setting on an ambulatory patient under simple local anaesthetic usually without the need for any sedation.

The guide-line markings are made on the nose with the patient sitting up to assess the degree of droop of the nose and get an impression of the amount of lift and rotation of the tip of the alar cartilages that will be required to get the ideal result and then to feel how much more the nose may comfortably be lifted to exaggerate the immediate result.

## **3. Standard markings**

**Figure 1.** Showing the markins on the lateral side of the nose for the standard nose.

3. The line will traverse the soft triangle of the nostril as it courses towards the lowest part of the columella. Usually this is at the position where the columella changes angle in the "ideal" nose.

154 Miniinvasive Face and Body Lifts – Closed Suture Lifts or Barbed Thread Lifts

7. Skin hook to free the skin from the buried thread

local anaesthetic usually without the need for any sedation.

8. 4/0 or 5/0 non-absorbable suture. This could be an elasticised suture as described by

The procedure is usually done in an office setting on an ambulatory patient under simple

The guide-line markings are made on the nose with the patient sitting up to assess the degree of droop of the nose and get an impression of the amount of lift and rotation of the tip of the alar cartilages that will be required to get the ideal result and then to feel how

1. A dot is placed to the right side of the dorsum of the nose immediately below the osteocartilagenous junction of the bridge of the nose, about 4 mm from the midline. This point is chosen so that when the anchoring transfixion suture goes through the cartilaginous septum, the tract will be anterior to the anterior nasal mucosal recess

2. Then a line is drawn on the side of the nose directed towards the lowest part of the

**Figure 1.** Showing the markins on the lateral side of the nose for the standard nose.

much more the nose may comfortably be lifted to exaggerate the immediate result.

5. Toothed Adson's forceps.

**3. Standard markings**

inside the nose.

columella (see Fig 1).

Serdev.

6. Fine needle holder to tie the knot.

4. As one draws this line one has to take into account the shape of the lower lateral alar cartilages. (See Fig 2). Normally as seen from the front in figure 2, the line is straight downwards.

**Figure 2.** Showing the skin markings for the standard nose

Percutaneous Suspension Sutures to Change the Nasal Tip 157

4. Once one reaches the layer just outside the upper lateral cartilage, change direction of

5. One has to distort the nose by pushing it medially and at the same time it is useful to put the Adson's forceps into the columella incision in order to retrieve the needlepoint.

6. The needle is now positioned outside of the nasal cartilages and the non-absorbable thread (4/0 or 5/0) is passed up the needle until it protrudes through the hub at the end

7. Pull back the needle until one reaches the entry point on the side of the nose, change direction to be perpendicular again and then push the needle through the septal cartilage to emerge through the opposite incision without catching any of the tissues attached to skin. This is the anchor so one has to be sure that the thread is not too close to the edge of the cartilage. It is easy to avoid the anterior nasal mucosal recess because it does not come into the sharp angle between the nasal septum and the upper lateral

8. Hold on to the thread and remove the needle. Most people expect that the bevel of the needle will cut the suture as it goes through the septum, but it generally never does. In doing this type of procedure for several thousands of times, the thread has been cut only twice. By this stage we have constructed more than half of the important loop that

9. The final stage is approached differently. The needle is now carefully inserted into the columella incision taking care not to catch any of the outer skin layer in the soft triangle of the left nostril and then pushed up to the stab incision on the left side of the nose. 10. By using the Adson's forceps one can guide the needle tip out through the stab incision

11. The thread is passed through the needle until it emerges from the needle hub before the

12. The suspension loop has now been created outside the upper and lower lateral alar cartilages and one can check what the nose looks like as one tightens the threads. The nose tip is lifted and the lower lateral alar cartilages are compressed towards each other

13. Examine the inside of the nostrils to be certain that the thread has not been accidentally placed medial to the alar cartilages. If this has been done and has not been detected,

14. It is advisable to make two throws in the same direction so that the knot can be adjusted before the third throw which seals the knot. A double throw is recommended and altogether I recommend about six throws to ensure that the knot never slips. The knot is

cut exactly on the knot so that the ends do not later protrude through the skin. 15. Always over-correct. In general it is unlikely that one over-corrects even though the nose tip is rather exaggeratedly lifted. Of course one should not over-correct too excessively. One major advantage of this operation is that it is easy to do and should one not over-correct sufficiently then the procedure is easy to repeat. The same is true

the needle and point it down under the guidelines previously marked.

Make sure that the needle does not catch any tissue of the columella.

will eventually narrow, rotate and lift the alar cartilages.

without catching the surrounding soft tissue.

then it might cause a chronic infection and pain.

of the needle.

cartilages

needle is pulled out.

medially and narrowed.

should one over-correct.

**Figure 3.** Showing the markings for a nose with broad alar dome cartilages.

## **4. Anaesthesia**

An inferior orbital nerve block should be done first and in some people this gives excellent anaesthesia of the whole nose especially if the local anaesthetic is placed in the inferior orbital foramen. In other people it may be necessary to add specific block to the lateral nasal nerves as well as the nerves at the nasal spine to the columella. By blocking these nerves, anaesthesia is achieved easily and painlessly. It is advisable to check that the septal cartilage is numb by infiltrating across to the other side where the anchors will be placed.

## **5. Placement of the suspension sutures**

4. Once one reaches the layer just outside the upper lateral cartilage, change direction of the needle and point it down under the guidelines previously marked.

156 Miniinvasive Face and Body Lifts – Closed Suture Lifts or Barbed Thread Lifts

**Figure 3.** Showing the markings for a nose with broad alar dome cartilages.

**5. Placement of the suspension sutures**

triangle" down towards the incision in the columella.

An inferior orbital nerve block should be done first and in some people this gives excellent anaesthesia of the whole nose especially if the local anaesthetic is placed in the inferior orbital foramen. In other people it may be necessary to add specific block to the lateral nasal nerves as well as the nerves at the nasal spine to the columella. By blocking these nerves, anaesthesia is achieved easily and painlessly. It is advisable to check that the septal cartilage

1. Two stab incisions need to be made at the points marked X in figures 1 and 2 and then use the sharp pointed scissors to make sure to dissect the skin away from the cartilage that the skin is entirely free of the surrounding deep tissues. These holes should be as

2. Make the incision on the columella and then dissect the skin away from the vertical alar cartilages in the area and extend the dissection area across into the "soft triangle" and even to the inferior edge of the lateral lower alar cartilages. By doing this one reduces the possibility of the needle passing into the nose as it is pushed across the "soft

3. Insert the chosen needle perpendicularly through the incision on the right side of the

is numb by infiltrating across to the other side where the anchors will be placed.

**4. Anaesthesia**

small as possible.

nose

16. Should you feel that the nose has not been adequately lifted a second suture can be inserted. I do not try and remove the first suture.

Percutaneous Suspension Sutures to Change the Nasal Tip 159

**Figure 5.** Showing the lateral marking for the shorter suture to compress the alar cartilages more

**Figure 6.** Showing the markings for a more pinched tip with the suture going through the septum

directly.

only.

## **6. Further modifications**

In some patients the described procedure makes a difference but one does not achieve the refinement of the nose tip that is desired. In these cases one needs to add extra sutures. Experience has shown that generally these sutures need to be shorter.

1. If the suture designed above will not narrow the nose sufficiently then one needs to add a suture lower down on the nose with more direct pressure on the upper edges of the lower lateral cartilages. (See Figs. 5 and 6)

**Figure 4.** Showing the frontal view of the skin markings where one needs more pressure on the alar wings.

As one creates this suture in much the same way as described above, take care to ensure that the alar cartilages are not lifted anteriorly which will create a ridge on the lower nose instead of maintaining a straight bridge to the tip, or supra-tip bump. This suture is often important for creating a really fine nose tip.. A variant that can be done, depending on the anatomy, is the pass above the lower lateral alar cartilages through the septum and then around them to make a more defined cinched tip (See Fig 6 and 7).

inserted. I do not try and remove the first suture.

Experience has shown that generally these sutures need to be shorter.

to 10 weeks one reaches a stable position.

the lower lateral cartilages. (See Figs. 5 and 6)

**6. Further modifications**

wings.

16. Should you feel that the nose has not been adequately lifted a second suture can be

17. I suggest taping the nose with micropore for about two days to limit swelling and also to ensure immobility. The nose tip can be rather sensitive for the first few days. 18. Over the next three to six weeks the nose tip will drop down into a stable position. By 8

In some patients the described procedure makes a difference but one does not achieve the refinement of the nose tip that is desired. In these cases one needs to add extra sutures.

1. If the suture designed above will not narrow the nose sufficiently then one needs to add a suture lower down on the nose with more direct pressure on the upper edges of

**Figure 4.** Showing the frontal view of the skin markings where one needs more pressure on the alar

around them to make a more defined cinched tip (See Fig 6 and 7).

As one creates this suture in much the same way as described above, take care to ensure that the alar cartilages are not lifted anteriorly which will create a ridge on the lower nose instead of maintaining a straight bridge to the tip, or supra-tip bump. This suture is often important for creating a really fine nose tip.. A variant that can be done, depending on the anatomy, is the pass above the lower lateral alar cartilages through the septum and then

**Figure 5.** Showing the lateral marking for the shorter suture to compress the alar cartilages more directly.

**Figure 6.** Showing the markings for a more pinched tip with the suture going through the septum only.

Percutaneous Suspension Sutures to Change the Nasal Tip 161

3. In some cases the alar cartilages are not positioned evenly and one cartilage may be lower than the other. In this case the displaced cartilage can be lifted by a loop created in the same fashion as described above but one goes medial to the "normal cartilage so that the one thread of the suspension loop lies in between the alar cartilages and the

**Figure 9.** Showing the surface markings of the suture used to pull up the left alar cartilage. It would be

Tightening the loop will lift the alar cartilage to a matching position and then the suspension suture for both alar cartilages can be positioned. Do not expect that a simple loop will

4. In cases of excessive bulk of the columella that hangs very low, then one should consider an elliptical excision of mucosa to lift the columella. Suspension sutures alone

Initially patients may worry that the tip of the nose has been lifted too much but if sensible exaggeration has been done, the nose takes up a pleasing position very quickly. (see Figures

For the first four five days the nose looks over-corrected but rapidly changes as the swelling disappears and within a week the patient feels much more confident. By ten weeks. Weeks

The nose can be rather sensitive to minor trauma and even to kissing but that also settles

the mirror image for the right side.

correct this type of asymmetry.

**7. Postoperative phase**

10 through 1)

cannot remedy this situation.

the nose has settled to very close to the final appearance.

quite soon. The patients may be aware of the suture for up to six months.

other part lies exterior to the lower cartilage as shown in figure 9.

**Figure 7.** Showing the composite view of both longer and then a shorter cinching suture to the nasal tip.

2. In some cases with very bulky lateral alar wings we need to do a slightly different suture to get better compression. Here it is necessary to make four stab incisions on the alar cartilage in a design that allows more compression on the alar cartilage and compresses the tip as well. (See Fig. 8)

**Figure 8.** Showing the square suture combination in the upper edge of the medial wing of the lower alar cartilage.

Here we have to be cautious about not entering the nasal cavity. These sutures do not need to be anchored to the septum. I rarely use this suture.

3. In some cases the alar cartilages are not positioned evenly and one cartilage may be lower than the other. In this case the displaced cartilage can be lifted by a loop created in the same fashion as described above but one goes medial to the "normal cartilage so that the one thread of the suspension loop lies in between the alar cartilages and the other part lies exterior to the lower cartilage as shown in figure 9.

**Figure 9.** Showing the surface markings of the suture used to pull up the left alar cartilage. It would be the mirror image for the right side.

Tightening the loop will lift the alar cartilage to a matching position and then the suspension suture for both alar cartilages can be positioned. Do not expect that a simple loop will correct this type of asymmetry.

4. In cases of excessive bulk of the columella that hangs very low, then one should consider an elliptical excision of mucosa to lift the columella. Suspension sutures alone cannot remedy this situation.

## **7. Postoperative phase**

160 Miniinvasive Face and Body Lifts – Closed Suture Lifts or Barbed Thread Lifts

compresses the tip as well. (See Fig. 8)

to be anchored to the septum. I rarely use this suture.

alar cartilage.

**Figure 7.** Showing the composite view of both longer and then a shorter cinching suture to the nasal tip.

**Figure 8.** Showing the square suture combination in the upper edge of the medial wing of the lower

Here we have to be cautious about not entering the nasal cavity. These sutures do not need

2. In some cases with very bulky lateral alar wings we need to do a slightly different suture to get better compression. Here it is necessary to make four stab incisions on the alar cartilage in a design that allows more compression on the alar cartilage and

> Initially patients may worry that the tip of the nose has been lifted too much but if sensible exaggeration has been done, the nose takes up a pleasing position very quickly. (see Figures 10 through 1)

> For the first four five days the nose looks over-corrected but rapidly changes as the swelling disappears and within a week the patient feels much more confident. By ten weeks. Weeks the nose has settled to very close to the final appearance.

> The nose can be rather sensitive to minor trauma and even to kissing but that also settles quite soon. The patients may be aware of the suture for up to six months.

**Chapter 6**

© 2013 Hidayani et al., licensee InTech. This is an open access chapter distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2013 Hidayani et al., licensee InTech. This is a paper distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**Chin Enhancement Using Serdev Suture:**

The main goal of aesthetic facial cosmetic surgery is to achieve balance and harmony to the facial features. Chin augmentation and correction are the most important procedures to obtain overall facial beauty. Chin augmentation has been conducted since 100 years ago. Some synthetic implant alloplastic materials have been used including the observation of benefits, loss, and complication accompanied with it. The beauty of the chin is one of the important factors to enhance aesthetic facial features, where the chin is the lower most from 3 facial parts. Aesthetically, protrusion of the chin should be parallel to the line of facial profile. Protrusion of the chin gives character to the face. However imperfection and protrusion of the chin as a result of trauma, congenital or aging may hinder an individual's appearance. Inconsistency between the bone and soft tissue is a common cause of impaired

Aging causes the skin to wrinkle and an increase in subcutaneous tissue causes change in projection and facial contour. This is caused by the laxity of the skin and facial muscles that support the gravity force. The area of the face that creases due to age includes cheeks and

There are many techniques/methods used to correct and tighten sagging facial skin, one of them by employing Serdev suture. This method involves lifting part of the face to correct the volume and position of the soft tissue with fixation of the fascia/muscle percutaneous without conventional incision. This method is preferably chosen because it is relatively safe (with minimal side effects), easy, and quick with satisfactory results. This method was invented by Dr. Nikolay P. Serdev. Besides chin lift, the method can also be applied to lift

Serdev suture involves passing sutures by needle into the soft tissue under the skin and stitched according to the desired purpose. This action can be performed in an outpatient

chin, which causes face disproportion in some individuals. [1,3,4]

other facial parts, buttocks and abdominal area. [2,5]

Meity Hidayani, Syarief Hidayat and Dali Amiruddin

Additional information is available at the end of the chapter

**Five Case Reports**

http://dx.doi.org/10.5772/56711

**1. Introduction**

aesthetic beauty. [1,2]

One realises quite quickly if the nose has not been over-corrected sufficiently. Patients should be warned that this is a possibility and that they might need a second minor procedure.

## **8. The advantages**

This is a simple low cost procedure easily done in the office that does not disrupt the alar cartilages and yet shapes them easily. It is rapidly done with little morbidity and the patient can rapidly return to normal social activity. The worst luck is that the nose might need some modification with some extra sutures.

One of the greatest advantages for older people is the improvement in breathing through their nose when the tip has been lifted. Another major advantage for people who have had previous surgery is how easily their nose can be re-fashioned into the nose they hoped for.

## **9. Summary**

A simple technique is always a benefit and this technique of lifting and compressing the nasal tip combines a very simple surgical procedure with rapid results and minimal discomfort. It can be used in old people whose nose tips have dropped and also in patients who have had a previous rhinoplasty. Its simplicity also makes it an inexpensive minimally invasive procedure that is also suitable for many minor nasal deformities.

## **Author details**

M. B. Des Fernandes *The Renaissance Body Science Institute, Cape Town, South Africa. Department of Plastic Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa*

## **Chin Enhancement Using Serdev Suture: Five Case Reports**

Meity Hidayani, Syarief Hidayat and Dali Amiruddin

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/56711

## **1. Introduction**

162 Miniinvasive Face and Body Lifts – Closed Suture Lifts or Barbed Thread Lifts

procedure.

**9. Summary**

**Author details**

*South Africa*

M. B. Des Fernandes

**8. The advantages**

modification with some extra sutures.

One realises quite quickly if the nose has not been over-corrected sufficiently. Patients should be warned that this is a possibility and that they might need a second minor

This is a simple low cost procedure easily done in the office that does not disrupt the alar cartilages and yet shapes them easily. It is rapidly done with little morbidity and the patient can rapidly return to normal social activity. The worst luck is that the nose might need some

One of the greatest advantages for older people is the improvement in breathing through their nose when the tip has been lifted. Another major advantage for people who have had previous surgery is how easily their nose can be re-fashioned into the nose they hoped for.

A simple technique is always a benefit and this technique of lifting and compressing the nasal tip combines a very simple surgical procedure with rapid results and minimal discomfort. It can be used in old people whose nose tips have dropped and also in patients who have had a previous rhinoplasty. Its simplicity also makes it an inexpensive minimally

*Department of Plastic Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town,*

invasive procedure that is also suitable for many minor nasal deformities.

*The Renaissance Body Science Institute, Cape Town, South Africa.*

The main goal of aesthetic facial cosmetic surgery is to achieve balance and harmony to the facial features. Chin augmentation and correction are the most important procedures to obtain overall facial beauty. Chin augmentation has been conducted since 100 years ago. Some synthetic implant alloplastic materials have been used including the observation of benefits, loss, and complication accompanied with it. The beauty of the chin is one of the important factors to enhance aesthetic facial features, where the chin is the lower most from 3 facial parts. Aesthetically, protrusion of the chin should be parallel to the line of facial profile. Protrusion of the chin gives character to the face. However imperfection and protrusion of the chin as a result of trauma, congenital or aging may hinder an individual's appearance. Inconsistency between the bone and soft tissue is a common cause of impaired aesthetic beauty. [1,2]

Aging causes the skin to wrinkle and an increase in subcutaneous tissue causes change in projection and facial contour. This is caused by the laxity of the skin and facial muscles that support the gravity force. The area of the face that creases due to age includes cheeks and chin, which causes face disproportion in some individuals. [1,3,4]

There are many techniques/methods used to correct and tighten sagging facial skin, one of them by employing Serdev suture. This method involves lifting part of the face to correct the volume and position of the soft tissue with fixation of the fascia/muscle percutaneous without conventional incision. This method is preferably chosen because it is relatively safe (with minimal side effects), easy, and quick with satisfactory results. This method was invented by Dr. Nikolay P. Serdev. Besides chin lift, the method can also be applied to lift other facial parts, buttocks and abdominal area. [2,5]

Serdev suture involves passing sutures by needle into the soft tissue under the skin and stitched according to the desired purpose. This action can be performed in an outpatient

unit because it is relatively safe and complications are relatively mild, such as edema, hematoma, infection and scar (rare). Patients must be selected, amongst others, patients must not have a history of heart disease, hypertension, uncontrolled diabetes mellitus, blood clotting disorders, and not taking any anti-coagulant medications; also the surgery is suggested not to be performed to patients who are under 20 years old due tothe mandible bone has not yet fully grown. [2,3,5,6]

Five cases of chin enhancementis reported on women ages between 40-53 years old using Serdev suture and without any complication.

## **2. Case reports**

#### **2.1. First case**

A 34-year old woman came to aesthetic clinic of Mintohardjo hospital for chin enhancement. From anamnesis, no chronic medical history is found like diabetes mellitus, hypertension, heart disease, or bleeding disturbances. In terms of physical examination, no abnormality to the chin is found. Routine laboratory blood test is within normal limits. With a clean medical

**Figure 1.** (A) and (B) Surgical instruments and materials prepared

**Figure 2.** (A) Pre-Operation (B) Post-operation

Chin Enhancement Using Serdev Suture: Five Case Reports 165

record, chin lift can be performed using Serdev suture and after the patient read,

2. Chin position is measured by drawing a line between the lower lip and chin, then place

6. Local anesthesia is given by injecting 2% lidocaine on the lowermost of the chin, under

7. Chin skin that has been marked is punctured using a special needle by following the

8. Serdev thread is inserted in the hole at the tip of the needle, and then pulled down, thus

9. Needle is inserted back to the lowermost chin following the outer chin muscle until it

10. Thread is inserted to the needle tip then pulled again until the thread appears in the

After the operation is completed, patient can perform activities as normal, however, the patient should take amioxcilin-clavulanic acid 3x500 mg for 5 days and administer

11. The tip of the thread is stitched to the first thread until reaching the desired chin lift.

understand, and agree to sign a medical consent.

a mark under the chin for needle insertion and exit point. .

4. Surgical instruments are disinfected using Betadine/povidone-iodine. 5. Sterile drapes are placed around the field to delineate sterile areas.

internal chin muscle until it penetrates the mark below inferior lip.

14. The wound is given betadine and covered with bandage as needed.

**Figure 3.** (A) marking for insertion and exit point (B) Anasthetic lidocaine 2%

penetrates to the same mark below the inferior lip.

1. Document chin from different angle.

3. The patient is laid on the operating bed.

appearing under the chin.

lowermost of the chin.

12. The thread is cut just above the knot. 13. The skin around the knot is freed.

mefenamic acid 3 times in one day if in pain.

15. Document the results after operation is finished.

SurgeryReport:

inferior lip.