A little more than a decade ago, Desmond B. Fernandes, M.D., realized, based on assessments of his facelift results, that "We weren't treating the midface properly. I believe one of the reasons why we run into midface problems is that when we sleep on our sides, we push our tissue toward the nose and downwards toward the mouth."
He is a plastic surgeon in private practice at the Renaissance Body Science Institute in Cape Town, South Africa, and is affiliated with the plastic surgery department at the University of Cape Town Medical School's Groote Schuur Hospital."When we lie on our side," he explains, "the tiny collagen fibers that hold the fat of the cheek onto the bone and deeper structures get stretched and may be broken."
To address this problem, he theorized that placing several stitches through the midface fat, particularly in the nasolabial region, and pulling them upward could return the fat to its correct position.
"Initially, I used to anchor the sutures very close to the hairline," Dr. Fernandes says. More specifically, he says this involved passing a 25 to 30 mm semicircular needle through the temporalis fascia, making sure to take a large enough 'bite' to compensate for the fact that the suture will cut through some of the fat in much the same way a cheese cutter works.
"We also must make sure that when lifting the fat, it's not going to rely only on the sutures to keep it in place. For that reason, I used to roughen the tissue between the cheekbone and the temporal hairline with a dissecting instrument" to ensure that healing would help keep the fat in place, he adds.
Dr. Fernandes says the part of the procedure that fascinates people is how he places the suture loop — which extends from the temple downward and around the midface fat, then back to the temple, where it is tied off — without leaving a scar. Perfecting this component required both inspiration and serendipity, he says.
Developing the procedure
Around 1995, Dr. Fernandes says, "I was working from the scalp with a complex tool that I had designed and trying to create the loop by passing a thread blindly through skin, hoping to get through two holes in the instrument. Then I realized that if one pushes a very fine spinal needle into the skin, deep into the fat, then pushes it up from the nasolabial fold toward the temporalis fascia, when it emerges (through a hole one has made in the temporal skin), one could pass a thread through that needle."
When one withdraws the threaded needle, he recommends coming close to the point where it was inserted but then changing direction to suture the fat superficially. "Or one can make a loop at a right angle to what I've described. By doing that, one only has a small needlepoint for a scar," Dr. Fernandes says.
As one pushes the needle back through the tissue, it drags the thread with it, which he says one should bring back out through a hole in the temple, thereby leaving two threads protruding through the skin in this area.
"One simply has to make a knot with both threads into the temporalis fascia. Then that new supporting thread is deep enough that one will never see it on the skin," he says.
Dr. Fernandes says other benefits of the procedure include its lack of bruising. "Because it's a relatively fine needle," he adds, "it will push away nerves rather than puncture through them."