Serdev Sutures® Lifts in Body Areas

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).


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.
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.
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.

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.

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".

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.

A.
B.  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.

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

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.

Tips and tricks
-Perforation point B could be located above the anus (preferable because of hygienic reasons) or below, and somewhat lateral from anus, in order to secure point B from contamination.

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If skin perforation point B is planned higher than the anus, an imaginary point B1 should be taken into consideration and when arriving from point A, deep under point B1, the needle direction should be changed to B as shown in Fig. 3.A.

-
If perforation point B is planned below the anus, the superficial fascia at that point B should be perforated very well and the perforation must be widened to avoid fixation with the needle and introduction into the suture. Otherwise, its attachment to the suture will produce dimpling. -Point C should be between both Serdev fascias, inside of the triangle of the sacral region. This will ensure that the passes C-B and C-A on both sides will cross the Serdev fascia from below and above, and the suture will be fixed to the Serdev fascia. Serdev fascia is perpendicular to the skin and sacral edges and the weight of the suture will be suspended on it. -Perforation of sacrococcigeal fascia and fixation of the suture on it produces ischiadic pain and should be avoided! -Do not fix the gluteus fascia or gluteus muscle to the suture. Both are immobile and will not permit lifting.
-Perform an oval, circular suture, in order to place equal tension to all points. Do not perform triangles or Z sutures. Higher tension in the angles will cut through the tissue and will not permit longevity of the lift.
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.

Technique
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)
-First pass -A-B: Introduce a long Serdev ® needle 170mm or 230mm from point A to point B1, deep in the soft fibrotic fat tissue. NB! The Serdev Suture ® circle should be located deep, just above the gluteus maximus fascia. Be sure not to be too superficial as it will cause skin/tissue dimpling on the path of the needle. If so, twist the needle backwards to free the superficial tissue and proceed deeper. Stay near, but above the gluteus fascia, which will block your needle if perforated. Arriving deep at B1, turn the needle toward B, as shown in Fig 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.
The close proximity of the wounds to the anus area makes antibiotic prophylaxis and strict hygiene obligatory.

Warnings
1. Do not perforate gluteal fascia or muscle. They cannot be lifted. 2. Do not perforate the sacrococcigeal fascia or periosteum at point C -this causes ischiadic pain. 3. Make a circular suture to obtain equal pressure around all points. Do not perform triangle sutures -tension on the angles will cut the tissue and produce pain.

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.

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).

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.

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.
-Higher pressure should be prevented, by performing a circle -a round form suture that equalizes pressure in all points and prevents from tension and trauma of the tissue. -Infection can be prevented with better selection of point B and antibiotic prophylaxis. The Bulgarian surgical sutures are antimicrobial, semi-elastic and are preferred by the author.
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.

Clinical cases
A. B.

Discussion
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.
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 mostly indicated.

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.

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

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.

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.

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).

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.
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.  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.

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).
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.

Anatomy
Anatomy landmarks are linea alba, superficial fascia, bone periosteum around the abdomen. 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.
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. Edema absorption in the fixation locations takes about a month.

Cephalic, lateral and distal lifting
Results are more than satisfactory. Selection of patients is important.

Conclusion
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.
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.

Nikolay Serdev
New Bulgarian University, Sofia, Bulgaria