Like many other facial plastic surgeons, early in my career I used various rhytidectomy techniques for my patients, such as deep plane, composite and superficial musculoaponeurotic system (SMAS) facelifts under general anesthesia. And, while I was obtaining great results, all that changed when I got recruited by “Lifestyle Lift,” a large corporate, high-volume practice where I was doing 10 to 12 facelifts per week. The procedures were performed in office, under local anesthesia and oral sedation. The company’s philosophy was “mini-lift and minimal results,” yet I was seeing people in their 60s and 70s who had quite a bit of tissue laxity, and I did not want to disappoint my patients with minimal results.
It was at this point that I realized I needed to develop an in-office technique that would produce maximum results for my patients under local anesthesia and oral sedation. Since it would be in-office, it could not be an extensive procedure like a deep plane or composite face- lift because those procedures require general anesthesia. Therefore, I needed to adapt myself and my techniques, but how?
I started by trying to combine the techniques I had learned from my mentors and experience to develop my own solution. During this time I was also doing cosmetic body surgery using extra-strong stitches (abdominoplasty requires double plication for durability). This sparked an idea – how can I apply this suturing to the face?
My breakthrough came in 2005 while at a cadaver lab. I went there often to try my new techniques on cadavers. It took a while, but finally I figured out how the sutures should start and end – a double layer of suturing starting with running mattress sutures, followed by running interlocking sutures.
It was a concept I was excited to try on my patients. I was thrilled that I could produce such excellent results without putting the patient under general anesthesia. I started doing it on more and more of my patients, and I was able to publish my Double-C plication technique in The American Journal of Cosmetic Surgery in 2011, based on 1,500 cases.
When I opened my private practice in Newport Beach, Calif., about a decade ago I had the desire to take my Double-C technique up a notch. I tried adding a third layer of plication and it worked!
My triple-layer plication technique is a “C” pattern marked on the periauricular SMAS extending inferiorly along the platysma up to the mastoid area. I use multiple interrupted sutures for the first and deepest layer (non-absorbable 2.0 Mersilene), which are permanent. On the second layer I use running mattress 2-0 Vicryl dissolvable sutures from Ethicon, Inc., and then running locking sutures (2.0 Vicryl) on top of that.
This technique provides an evenly distributed radial traction on the SMAS and lateral platysma, allowing for a more uniform suspension than traditional single interrupted plication sutures, which only offer point-specific tension.
The beauty of my technique is that I can vary the tightening in the neck area. If somebody has a super heavy neck, I can pull more. So, no matter what kind of neck a patient has, I can achieve maximum results on the neck lift without compromising the face. In comparison, in a deep plane facelift you would pull the whole thing together, but sometimes there is excessive neck laxity, and if you pull the neck too much, it affects the face by creating a “pulled” look. With my technique, I can adjust each stable point in the facial area accordingly without compromising anything.
There was a study done at Georgetown University in 2008 between the Otolaryngology and Mechanical and Aerospace Engineering departments to validate my technique. The conclusion was that the double-layered running locking technique requires more force on a pigskin with a tensiometer than the horizontal mattress technique, which causes a significant failure of plication. My triple layer plication adds yet another layer of security to the suturing.
In 2020 I published my triple layer plication technique in the Plastic and Reconstructive Surgery - Global Open journal. So far, I’ve done nearly 5,000 face and neck lifts in combination with the double C plication and triple-layer plication techniques.
I have a huge practice in facelifts, thanks not only to my technique, but because many of my patients do not want to go under general anesthesia, but they still want maximum results that look natural. My technique has become so popular I have people from all over the world traveling to get their procedure done.
About the Author
Kevin Sadati, DO
Dr. Sadati is a board-certified facial plastic surgeon in Newport Beach, Calif. He has over 15 years of experience and has performed over 4,000 face and neck lift procedures utilizing his self-developed facial muscle tightening technique, the Triple C Plication, for facial rejuvenation. Along with years of studying and training, Dr. Sadati has experience as a painter and sculptor, which embodies his artistic eye for, and appreciation of, aesthetic harmony.
