Nurse prescriber Yuliya Culley describes treating a younger patient to improve jawline definition
A 39-year-old female Caucasian patient presented to Novello Skin clinic with concerns about her jawline definition. She requested a reduction in skin laxity and jowling, noting that she used to have a much more defined jawline, but this had been affected by age and fluctuations in her weight. Even though she had been maintaining a healthy lifestyle, with regular exercise and a good skincare routine, she believed that her jawline created an impression of extra weight. The patient felt that the contours of her face were important in helping her project a youthful appearance and maintaining her self-confidence.
The patient had undergone a number of previous treatments at our clinic and, as a result, we knew that her medical history indicated no underlying conditions. Previously we had put a gradual treatment plan in place according to her anatomical features, starting with a mid-face treatment using Juvéderm Voluma and chin treatment with Juvéderm Volux. Although these had a positive outcome, the patient felt that more lift to her jawline was required to achieve a better result for her whole face. We looked at several options for the jawline treatment such as jaw contouring with dermal filler, radiofrequency skin tightening and thread lift. We eventually decided that a non-surgical thread lift would be beneficial for achieving a desirable instant outcome and long-lasting results, which would improve gradually due to collagen stimulation over time. The decision to opt for a Silhouette Soft procedure for the jawline was influenced by several factors such as the product’s high safety profile, collagen type 1 stimulation, as well as previous well-presented case studies for mild to moderate skin laxity.1-3
The Patients’ Selection guide 4 for the Silhouette Soft procedure was used to establish suitability of the procedure for this patient. In order to achieve satisfactory results, the indication for treatment is mild to moderate tissue sagginess.1 In this case, the patient’s jawline area was graded as mild sagginess.
I always offer a cooling-off period prior to treatment to help patients make an informed decision. This is particularly important in the case of a thread lift as it requires compliance with aftercare guidance, including avoidance of makeup for 24 hours after the procedure, limitation of activities such as facial exercise and high impact sports for two to four weeks, a softer diet for the first week, and avoidance of dental treatments for up to four weeks afterwards.3 I made sure all aspects were covered during the initial consultation to ensure the patient could make relevant arrangements and be fully prepared for the procedure, as well as leaving herself enough time to recover afterwards. I have found that when patients are provided with aftercare instructions and are well prepared for the downtime following the procedure, they are not surprised or concerned about mild side effects.2
The patient was asked to arrive without makeup on the day to minimise the risk of infection. She also was advised to avoid drinking alcohol and taking omega-3 fatty acids and vitamin E preparations for two to three days prior to the procedure, in order to minimise the risk of bruising.5 Traditionally, non-steroidal anti-inflammatory drugs such as Ibuprofen are avoided prior and post some aesthetic procedures and dermatology surgery, however the evidence of increased bleeding in relation to their use is subjective.6 The procedure does require a longer treatment time than fillers or botulinum toxin injections. My advice to patients is to allow two hours in the clinic for skin preparation, careful marking-up of the areas to be treated, as well as application of local anaesthesia to make the procedure more comfortable.
Skin preparation with antiseptic, an aseptic protocol, meticulous marking of treated areas and technique is vital for successful outcomes and reduction of possible side effects such as excessive swelling, bruising, thread protrusion due to incorrect placement, facial asymmetry and infection.2 The environment is also an important factor to consider, including ensuring the treatment room is equipped with good lighting, a comfortable temperature, procedure consumables, and assistance is available.
Before the procedure, the medical history of the patient was reviewed again, including a treatment plan recap and a photographic assessment. After initial skin cleansing with Clinisept+, the skin was marked with a Silhouette Soft ruler (Figure 1) and an iodine solution was applied on the tip of the wooden cotton swab. I prefer this marking technique to the water-soluble marker for infection control reasons, providing patients do not have allergies to iodine. For this patient, one entry point for the insertion of the threads was marked at a 1.5cm point inferiorly to the mandibular angle on both sides. The exit points were marked in the submental region and sternocleidomastoid muscle area on both sides. Xylocaine was used for the local anaesthesia with 0.2- 0.3ml (using a 30 gauge needle attached to the syringe with anaesthetic) at the entry and exit points of the sutures. Eight-coned sutures/6cm – the smallest sutures in Silhouette Soft family (12 and 16 cones are available) – were chosen for this procedure, based on my clinical judgment to approach the patient with petite facial features in this way to ensure full submersion of cones into the subcutaneous tissue.
The entry point hole was made with a 18 gauge needle and was used for both needles, attached by the manufacturer at each end of the suture, which were inserted under a 90° angle, placed in opposite directions to each other to achieve the tissue traction, firm soft tissue anchoring and consequent lift.7 The inner needle was moved subcutaneously from the entry point anteriorly to the exit point in the submental region; the opposite needle was advanced subcutaneously posteriorly towards the exit in the sternocleidomastoid muscle area.7
The overall insertion of the sutures on both sides took around 20 minutes. An important step in this particular thread lift technique for the jawline and neck area is to locate superficial vessels due to a higher rate of ecchymosis post-procedure in these areas.7 The correct traction and pulling technique of the cones is important to avoid protrusion and breakage of the threads.2 The manual compression and moulding of the anterior part of the cones first and suspension thread (posterior) end afterwards was performed. To avoid possible asymmetry, I compared lifting effect on both side of the patient’s face/neck in an upright position, before cutting off the suture ends.
Additionally, this approach helps to avoid potential post-procedure suture extrusion that could lead to skin irregularities and irritation.2 After careful examination of the entry and exit points to ensure that the threads were submerged in the subcutaneous tissue, Chloramphenicol ointment was applied topically, with the purpose of prophylaxis of potential procedure site infection at the suture entry and exit points.
Chloramphenicol ointment topical application on surgical wounds outside of ophthalmic surgery was chosen by 69% of plastic surgeons with wound infection prophylaxis and indicated a 40% lower infection rate.8 However, there are limitations in methodologies, with only a small number of randomised controlled studies for surgical wounds in other medical fields.8,9 Therefore, there is not statistically sufficient data on infection reduction in surgical wound with application in aesthetics, hence further research on the application of chloramphenicol in the aesthetic medical field is advised. Overall, the patient found the procedure much more comfortable than expected, but did experience a feeling of skin tightening, swelling and soreness in the treated areas. All these side effects were expected and covered during the initial consultation.
As part of the patient’s aftercare, a light-emitting diode (LED) therapy session was incorporated straight after treatment to stimulate healing and minimise potential swelling and inflammation.10,11 The patient was observed in clinic for 30 minutes after the procedure, with vital signs checked such as blood pressure, temperature, respiration rate and SaO2 levels. Additionally, an aftercare pack was provided, which included Cebelia L.C.E balm that aims to assist in bruising and swelling reduction, and Luxeface lifting mask for mechanical support of the treated areas, hydration and anti-inflammatory activity.
The patient was reviewed one week post-treatment to ensure a satisfactory healing process was taking place, which it was, and four weeks later to observe the results once the inflammation fully settled.
The patient was satisfied with the outcome of her Silhouette Soft thread lift procedure for jawline contouring, noting in her feedback that the immediate, noticeable jawline lift was observed after one treatment. As many patients prefer to undergo less invasive procedures rather than surgical solutions with longer downtime, the thread lift techniques provides us with a way to meet this growing demand.12 However, the Silhouette Soft procedure is an advanced technique requiring knowledge and skills to achieve positive results and minimise side effects. According to the Care Quality Commission (CQC), in England any procedures that incorporate insertion of instruments or equipment into the body, including thread lift, must be CQC registered by law.13 There is still unclarity regarding clinical standards by CQC around suture lift procedures to date. Currently, in the UK only medical practitioners who have been trained by Sinclair Pharma can perform Silhouette Soft lift, which is described as an in-office procedure, demanding aseptic technique and high training level.14
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