Keywords
quilting sutures - platysma - SMAS - Indian skin - facelift - hyperpigmentation
Introduction
Hematoma is one of the most frequent and concerning complications following facelift
surgery, with reported incidence rates ranging from 0.6 to 14.2%.[1]
[2]
[3]
[4] This complication not only increases postoperative morbidity due to ischemia, infection,
fibrosis, and necrosis but also prolongs recovery by causing edema, ecchymosis, and
seroma formation.[4]
[5] Addressing this issue has led to the development of innovative techniques aimed
at reducing the occurrence of hematoma and other complications.
One such advancement is the use of quilting sutures or hemostatic nets, which can
be applied either externally or internally.[6]
[7]
[8]
[9] These sutures work by reducing dead space between the skin and the superficial musculoaponeurotic
system (SMAS), thereby significantly lowering the risk of hematoma. Beyond reducing
the incidence of hematomas, hemostatic nets also minimize swelling and bruising while
promoting a more uniform distribution of skin tension across the flap. This, in turn,
improves blood supply, decreases ischemia and necrosis rates, and leads to better
scar quality.
The use of quilting sutures offers additional benefits by allowing for more precise
redraping of the skin over the SMAS, which is particularly advantageous in patients
with deep wrinkles or those undergoing extensive dissection. External quilting, first
introduced by Auersvald et al, has been effective,[10] but it has also been associated with complications such as hyperpigmentation at
needle puncture sites, especially in patients with Fitzpatrick skin types III and
IV.[6]
[10] Moreover, external quilting does not address the risk of delayed hematoma, leaving
room for improvement in certain patient populations.[11]
Internal quilting sutures (IQS) were first demonstrated by Baroudi and Ferreira in
1993, but did not gain popularity over the years.[12] Pollock and Pollock also described progressive tension suturing to shorten the convalescence
and help in better tissue redraping in a small series of patients; however, this technique
did not gain popularity.[8]
IQS provide more robust structural support, helping reposition facial tissues while
simultaneously promoting tissue regeneration and collagen production. Over time, this
approach can lead to more stable, long-lasting results compared to traditional facelifts.
Despite the potential benefits, there is a paucity of literature on the use of IQS
in patients with skin of color, particularly those with Fitzpatrick skin types III
to V. Considering the specific characteristics of this patient population, this study
aims to evaluate the technique and effectiveness of IQS (internal hemostatic nets)
in higher Fitzpatrick skin types (especially Indian and Middle Eastern patients).
Materials and Methods
This study adhered to the ethical guidelines set by the World Medical Association's
Declaration of Helsinki for research involving human subjects. Between February 2019
and October 2024, 41 consecutive patients underwent facelift surgery performed by
the same surgical team, and informed consent was secured from all participants. The
inclusion criteria included patients with Fitzpatrick skin types III to V, Indian
or Middle Eastern ethnicity, thick skin, and SMAS. These patients required face and
neck lifts, with or without additional facial rejuvenation procedures, such as blepharoplasty,
browpexy, and facial fat grafting. All patients were counseled regarding the possibility
of transient dimpling in the early postoperative period.
Patient demographic data, including age, gender, ethnicity, smoking status, comorbidities,
and Fitzpatrick skin type, were recorded. Details of each surgical procedure, including
addition of submental platysmaplasty, were also documented. All patients were observed
closely for early complications within the first 72 hours postsurgery, including hematoma,
ischemia, necrosis, excessive bruising, swelling, and nerve palsy. Hematoma was defined
as a blood collection exceeding 30 mL that required surgical drainage.[13]
[14] Ischemia was characterized by an area at least 1 cm2 in size with a purple hue and slower capillary refill than surrounding skin. Necrosis
was defined as a blackened area of at least 1 cm2 with no visible perfusion.[6]
Edema and bruising were graded on a scale of 1 to 5 based on patient-reported severity.[15] Preoperative and postoperative photographs were obtained. Drains were removed and
patients were discharged on postoperative day (POD) 1, at which point compression
garments were applied. Follow-up visits occurred on POD 7, 1 month, 3 months, and
6 months postsurgery to document delayed complications, such as skin dimpling, seroma,
and sialorrhea.
Surgical Procedure
The platysma-SMAS plication facelift procedure was performed under general anesthesia
or intravenous sedation, combined with local anesthesia. Tumescent fluid containing
300-mL normal saline, 30-mL 2% plain lignocaine, 1.5-mL adrenaline, and 40-mg triamcinolone
was injected using a 20-mL syringe with a 21-gauge needle along the incision lines,
and a 1.8-mm cannula was employed to infiltrate the midface, lower face, staying above
the SMAS layer and the neck and submental regions, ensuring protection of critical
structures such as the marginal mandibular nerve and external jugular vein in the
premasseteric area ([Video 1]).
Video 1 Demonstration of internal quilting sutures in a facelift procedure.
Next, ultrasound-/liposuction-assisted dissection was performed using a power-assisted
liposuction device or suction- assisted canula, which helped bluntly dissect tissue
planes in the premasseteric, lower face, submental, and neck areas. Liposuction was
performed in the superficial fat compartment only, which was the plane of flap elevation
for subcutaneous facelift.
Follicle-preserving incisions were made into the temporal region, followed by preauricular
incisions incorporating V and Z patterns to minimize straight-line contracture. Sharp
dissection proceeded deep to the subcutaneous plane, taking care to preserve the superficial
temporal artery and the temporal branch of the facial nerve. The skin flap is elevated
at the hypodermis level with a thin layer of subcutaneous fat. The dissection extended
below the ear lobule into the neck, where the external jugular vein was carefully
preserved.
The zygomatic arch was marked, and a low SMAS incision was made parallel to and 1.5 cm
below the arch. A vertical SMAS incision was made in the premasseteric fascia, exposing
the buccal branch of the facial nerve, which were protected throughout the procedure.
The SMAS dissection was done using scissors, and hemostasis was achieved using bipolar
cautery. The SMAS was then secured to the periosteum of zygoma using a three-point
fixation, in a lifted position, and the buccal fat pad was suspended using 3–0 polydioxanone
sutures. The jowl fat was lifted and fixed in place, while the platysma was lifted
and anchored below the mandibular angle. The mandibular angle was further augmented
by suspending the SMAS fat.
IQS were then applied using 4–0 rapid undyed Vicryl. These sutures were placed between
the subcutaneous tissue and the SMAS at intervals of approximately 1 cm (roughly 16–20
sutures), progressively distributing the skin tension. The vector of advancement was
individualized for each patient.
Redundant skin was excised, and skin flaps were trimmed and inset in a tension-free
manner. The temporal skin was anchored to the superficial temporal fascia. A suction
drain was placed on each side. The incisions were closed in two layers using interrupted
4–0 Vicryl and 4–0 Monocryl sutures. Absorbent dressings were placed for 24 hours
and drains were removed on POD 1. IQS contributed to an addition of approximately
15 minutes to the whole duration of the facelift procedure.
Results
Forty-one patients underwent rhytidectomy, with a mean age of 55 years (standard deviation
[SD]: 8.7; range: 38–72 years). The cohort included 6 (14.6%) males and 35 (85.4%)
females. Regarding ethnicity, 13 (31.7%) patients were of Mediterranean or Middle
Eastern descent, while 28 were Asian. Fitzpatrick skin type III was present in 17
(41.5%) cases, type IV in 20 (48.8%) cases, and type V in 4(9.75%) cases. The mean
follow-up duration was 37.2 months (SD: 13.6 months).
Of the 41 procedures, 26 (63.4%) were performed under general anesthesia and 15 (36.6%)
were conducted using intravenous sedation combined with local anesthesia. The ancillary
procedures performed in conjunction with rhytidectomy included 7 (17.1%) lower lid
blepharoplasties, 3 (7.3%) upper lid blepharoplasties, 3 (7.3%) browpexies, 1 (2.4%)
alar width reduction, and 5 (12.2%) facial fat grafting procedures.
Regarding patient comorbidities, 7 (17.1%) had diabetes mellitus, 8 (19.5%) had hypertension,
1 (2.4%) had rheumatoid arthritis, 1 (2.4%) had Sjögren's syndrome, 1 (2.4%) had glucose-6-phosphate
dehydrogenase (G6PD) deficiency, 1 (2.4%) had systemic lupus erythematosus (SLE),
and 1 (2.4%) had cutis laxa. Three (7.3%) patients were active smokers and three were
on aspirin.
Postoperative complications were minimal ([Figs. 1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]). No cases of hematoma or seroma were recorded. There was one case of dehiscence
in a patient with both diabetes mellitus and a history of smoking. Transient dimpling
was observed in seven (17.1%) patients, and two (4.9%) patients developed dog-ears,
both of which resolved within 3 months of follow-up.
Fig. 1 60-year-old woman following a platysma-SMAS plication facelift procedure with internal
quilting sutures. (A, B) Before surgery. (C, D) After surgery. (E, F) Postoperative day 1 photographs showing minimal bruising. SMAS, superficial musculoaponeurotic
system.
Fig. 2 45-year-old woman following a platysma-SMAS plication facelift procedure with internal
quilting sutures. (A, C) Before surgery. (B, D) Postoperative day 5 photographs showing minimal bruising. SMAS, superficial musculoaponeurotic
system.
Fig. 3 58-year-old woman a following platysma-SMAS plication facelift procedure with internal
quilting sutures. (A, B) Before surgery. (C, D) After surgery. (E, F) Postoperative day 2 photographs showing minimal bruising. SMAS, superficial musculoaponeurotic
system.
Fig. 4 65-year-old woman following a platysma-SMAS plication facelift surgery with internal
quilting sutures. (A, B) Before surgery. (C, D) Postoperative day 7 photographs showing minimal bruising. SMAS, superficial musculoaponeurotic
system.
Fig. 5 63-year-old woman following a platysma-SMAS plication facelift procedure with internal
quilting sutures. (A, B) Before surgery. (C, D) Postoperative day 3 photographs showing minimal bruising. SMAS, superficial musculoaponeurotic
system.
Fig. 6 60-year-old man following a platysma-SMAS plication facelift procedure with internal
quilting sutures with upper and lower lid blepharoplasty. (A–C) Before surgery. (D–F) Postoperative day 1 photographs showing minimal bruising. SMAS, superficial musculoaponeurotic
system.
Fig. 7 62-year-old woman following a platysma-SMAS plication facelift procedure with internal
quilting sutures. (A, B) Before surgery. (C, D) Three-month postoperative photographs showing well-defined facial and neck contours.
SMAS, superficial musculoaponeurotic system.
Fig. 8 59-year-old woman following a platysma-SMAS plication facelift procedure with internal
quilting sutures. (A–C) Before surgery. (C–E) Long-term postoperative results showing stable long-lasting results maintaining
facial and neck contour at 6 months. SMAS, superficial musculoaponeurotic system.
Discussion
Minimizing hematoma formation in facelift surgeries is crucial for reducing postoperative
complications and surgical downtime. Hematomas not only prolong recovery but can also
increase the risk of morbidity, including edema, ischemia, infection, and necrosis.
Various strategies have been proposed to address this issue, including the use of
fibrin sealants, multimodal blood pressure management, tumescent infiltration, exclusion
of adrenaline in infiltration solutions, and low-pressure suction drains, and use
of harmonic blade for dissection.[16]
[17]
[18]
[19]
[20]
[21]
[22] However, these techniques have not consistently demonstrated superiority or applicability
across all patient demographics.
One established approach is the use of the Auersvald hemostatic net,[6] which has shown success in reducing hematoma incidence, though cases of delayed
hematoma have been reported, particularly when sutures are removed at 48 hours.[11] To counter this, Auersvald et al extended the duration of net placement to 3 days
for females and 4 days for males, providing added stability for blood coagulation
in the surgical area.[23] This protocol has proven effective, especially in patients who require pharmacological
anticoagulation, without posing additional risks to healing. This extended timeline
is pertinent especially for patients on thromboembolism prophylaxis, as it helps further
mitigate hematoma risk.
Auersvald et al have recently advocated for the use of a 5–0 nylon suture with a 30-mm
3/8 cutting needle (Monosof; Covidien, Minas Gerais, Brazil), which they found particularly
beneficial for patients with thicker skin and more substantial subcutaneous tissue,
such as those with Indian skin types. However, availability of this specific needle
is limited globally.[23] In the instances where the preferred needle is unavailable, our proposed approach
of using internal suturing between the skin and SMAS can still be achieved with smaller
needles, potentially without compromising efficacy.
External hemostatic sutures, while effective, bring added challenges, including an
initial “ghastly” appearance that can be unsettling for patients. Additionally, leaving
external sutures in place for 4 days may increase the risk of hyperpigmentation, especially
in patients with Fitzpatrick skin types III to V. Notably, there are no published
data on the impact of the Auersvald modified protocol on patients of color, an area
that warrants further exploration to ensure safe and aesthetic outcomes in diverse
populations.[22] In a previous study by Auersvald et al, 17.1% of patients, particularly those with
darker skin types (Fitzpatrick III and IV), experienced hyperpigmentation at needle
puncture sites, while three patients developed persistent hypopigmentation.[6]
[10] To manage this, they employed topical hydroquinone 2% for a month.
There are limited data on the long-term effects of this approach, especially in patients
of color. Moreover, the removal of external sutures afterward often requires the expertise
of the surgeon or well-trained staff, adding to the postoperative burden. There is
still a risk of seroma formation following suture removal, which can complicate recovery.
Risk of hematoma under SMAS is a very limited risk and needs direct visualization
and coagulation using bipolar cautery. Subcutaneous hematoma is a bigger risk as there
is significant degloving of skin and small subdermal vessels can bleed postoperatively.
The role of drains alongside hemostatic sutures in facelifts is still debated. Although
internal hemostatic sutures can significantly reduce dead space and mitigate fluid
accumulation, drains may still serve as a useful adjunct by providing a conduit for
residual fluid efflux, particularly in cases with extensive tissue manipulation or
patients at higher risk of fluid retention.[24] Studies examining the use of quilting sutures in abdominoplasty, for instance, have
found that drains remain beneficial in reducing postoperative seroma, suggesting a
potential parallel benefit in rhytidectomy.[9]
[25]
In contrast, IQS, or an internal hemostatic net, offer several advantages over the
external method ([Table 1]). Internal quilting preserves the benefits of external hemostatic nets, such as
reducing skin tension and enhancing skin redraping, without the need for visible sutures.
The possibility of hypertrophy of scar, stretching of scars and pixie ears are more
if tension is directly on the skin or subcutaneous sutures. By progressively reducing
tension on the skin flaps, internal sutures facilitate more precise tissue repositioning,
leading to a more natural and aesthetically pleasing result. Additionally, the internal
technique eliminates the need for suture removal and avoids the appearance-related
concerns and hyperpigmentation risks associated with external quilting.
Table 1
Summary of the advantages of Internal Quilting Sutures
|
1
|
Provide natural results
|
The IQS technique provides superior tissue repositioning, resulting in less tension
on the suture line and better skin redraping
|
|
2
|
Quick downtime
|
It offers effective hemostasis and, thus, can shorten recovery time by reducing the
edema and excessive bruising compared to traditional facelift techniques
|
|
3
|
Minimizing complications
|
By reducing dead space and providing better support for facial tissues, the internal
hemostatic net decreases the likelihood of complications such as hematoma, seroma,
and prolonged swelling
|
|
4
|
Long-term effectiveness
|
The structural support offered by internal quilting sutures contributes to more stable
and long-lasting results, maintaining facial contours and minimizing skin laxity over
time
|
The only contraindication was when the skin was very thin, but in our series of patients
with skin types III, IV, and V, the skin was found to be thick enough to place internal
sutures without risks. As the skin flap was elevated at the hypodermis level with
a thin layer of subcutaneous fat, there was occasional risk of dimpling, but it was
found to be transient, as 4–0 Vicryl Rapid dissolves within 2 weeks. Transient dimpling
was observed in seven (17.1%) patients, which resolved within 3 months of follow-up.
We did not objectively measure skin flap thickness in our case series. However, a
prospective study that quantifies the exact thickness of the skin flap and fat layer
would provide a more systematic approach to determining whether external or internal
quilting is better suited for different skin and subcutaneous tissue thicknesses.
Conclusion
While external quilting sutures have provided valuable improvements in facelift surgeries,
the IQS/hemostatic net (IQS) technique offers a refined, less invasive alternative.
It not only reduces complications and improves recovery but also achieves more natural,
enduring results, especially in patients with thicker skin and higher Fitzpatrick
skin types.
