Abstract:
A surgical instrument is provided, principally for use with endoscopic plastic surgery, and adapted for insertion into an incision for engaging subcutaneous tissue, fat, fascia or muscle (STFFM) through a remote access incision, grasping the STFFM, and enabling it to be moved to another location. The STFFM is grasped preferably by engaging it with a needle and passing a suture through it, with the suture being locked by engagement via a hook, all at a location inside the skin that is remote from the opening. This enables the sutured STFFM to be moved, in any direction, but most often toward the incision as the inserted portion of the instrument is removed. A vacuum and an external clamp are provided, for facilitating engagement of the portion of the STFFM that is to be sutured. The instrument is usable for facelift surgery, midface surgery, brow surgery, neck lift, scalp reduction, endoscopic mastopexy, endoscopic thigh lift, endoscopic tummy tuck, and for any other technique where it is desired to shift STFFM from one location to another location, as for example, in the correction of undesirable liposuction results.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
       [0001]    This is a continuation-in-part of application Ser. No. 11/341,161 filed Jan. 27, 2006, which is a continuation of application Ser. No. 10/336,277 filed Jan. 3, 2003, now U.S. Pat. No. 7,060,079 dated Jun. 13, 2006. 
     
    
     BACKGROUND OF THE INVENTION 
       [0002]    Endoscopic surgery has evolved such that many operations are being performed through incisions of ever-decreasing size. Endoscopic surgery classically can be performed with incisions as small as 4 mm. The greatest limitations in performing endoscopic surgery through an incision of this size is the difficulty of engaging tissue and passing sutures to a location remote from the access point to a remote location under the surface of the skin. While some surgeons develop the manual dexterity and experience to effectively suture tissue at the internal location remote from the incision, very few techniques have been developed to deal with this problem effectively. 
         [0003]    Often surgeons are forced to make additional incisions, simply because of the difficulty of needle passage. For example, in performing an endoscopic facelift, the surgeon is often forced to place an incision inside the mouth or through the desired location in the skin surface. They are also obliged to widely undermine (make large internal incisions) to clear enough space within the internal space viewed by endoscopy to allow the instrumentation in that is to pass and then retrieve the needle. With manual remote access techniques, often a significant amount of skin must be (lifted) undermined from the underlying fascia, fat and musculature to allow room to maneuver an endoscope, a needle holder, and the grasping forceps. Often 4 hands are necessary (surgeon+assistant) to hold the instrumentation and pass the needle. 
         [0004]    The limitations of currently available techniques as discussed above produce certain potential surgical risks including needle breakage within the face, needle loss within the face, injury to the facial nerve, its branches, sensory nerves, and blood vessels, dimpling in the skin, improper needle location, inability to pass the suture to obtain the desired lifting effect, as well as the need to open the area completely to retrieve a lost needle or for repair of nerves or vessels. 
       SUMMARY OF INVENTION 
       [0005]    The present invention is directed to providing an instrument for endoscopically surgically engaging and grasping the deep surface of the skin, fascia, fat, or muscle of a patient. This allows the suture to be employed to engage and lift the grasped tissue such that it can be sutured to stable supporting tissue in order to obtain a suture “lift” of the deep tissue along with the skin. An endoscopic instrument is inserted into the opening, preferably carrying a suture. Preferably, vacuum is applied through the instrument for engaging the skin, muscle, fat, fascia, or other subcutaneous tissue at a precise location that is determined by turning on the vacuum in the instrument and gauging, and refining vacuum placement so that the optimum vector of lift and thus the optimum location of suture placement is verified. Optionally, an external clamp is then placed over the exterior surface of the skin to assist the vacuum engagement of the skin and to verify the location inside the tissue that is sutured, due to visual placement of the clamp on the external surface of the skin. A straight needle then passes outside the suction apparatus, carrying the suture as it passes through the skin that is to be engaged. Preferably, a hook carried by the instrument then hooks the suture that has been passed through the deep tissue. The hooked suture, passed through the deep tissue, may then be withdrawn as the instrument is withdrawn. 
         [0006]    Accordingly, it is an object of this invention to provide a remote access endoscopic suture passer. 
         [0007]    It is another object of the present invention to provide an instrument for endoscopically surgically engaging and grasping the deep subcutaneous tissue, fascia, fat, or muscle of a patient internally and remote from a skin access opening in order to engage the grasped tissues and skin relative to the opening. 
         [0008]    It is a further object of this invention to accomplish the above object, wherein the deep subcutaneous tissue, fascia, fat, or muscle that is engaged and grasped is sutured with a needle, and with the suture being hooked to the instrument such that the engaged and sutured deep subcutaneous tissue, fascia, fat, or muscle may be moved toward the access opening of the skin as the instrument is withdrawn through that opening. 
         [0009]    It is another object of this invention to facilitate suturing of the deep subcutaneous tissue, fascia, fat, or muscle via a vacuum delivery through the instrument, such that the vacuum is used to engage the tissues internally in order to facilitate suturing the deep subcutaneous tissue, fascia, fat, or muscle. The object of the vacuum within this instrument is to allow assessment of optimum suture placement such that the desired vector or lift can be achieved without creating dimpling or an unnatural look. Furthermore, the vacuum is used to facilitate needle passage. 
         [0010]    It is a further object of this invention to accomplish the above objects, wherein a clamp is applied to the outside of the skin, just outside the location where the inside tissue is to be sutured, in order to facilitate the engagement of the inside portion of the deep subcutaneous tissue, fascia, fat, or muscle that is to be sutured. 
         [0011]    It is another object of this invention to accomplish the above objects for facilitating all aesthetic surgery including facelifts, brow surgery, breast lifts, thigh lifts, abdominal lifts, skin deep subcutaneous tissue, fascia, fat, or muscle shifting from one location to another, and deep suturing of flaps. 
         [0012]    It is another object of this invention to accomplish suturing of this sort in deep subcutaneous tissue, fascia, fat, or muscle in endoscopic procedures including general surgery, laparoscopic obstetric and gynecologic surgery, and in arthroscopic orthopedic and podiatric surgery. 
         [0013]    It is another object to provide an enclosed system for suture passage that is self-retrieving, without the need for regrasping and/or a protected needle enclosed within a system. 
         [0014]    It is another object of the invention to use vacuum on the STFFM as a localization system in order to decide exactly where the optimum vector of lifting is to occur. 
         [0015]    It is a further object of this invention to provide an alternative to the external device and/or vacuum application, to be applied through the use of a toothed forceps for internally grasping the subcutaneous tissue, fat, fascia, or muscle in lieu of, or in addition to, the above proposed mechanisms. 
         [0016]    Other objects and advantages of the present invention will be readily understood upon a reading of the following brief descriptions of the drawing figures, the detailed descriptions of the preferred embodiments, and the appended claims. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWING FIGURES  
         [0017]      FIG. 1  is an illustration of the instrument of this invention being applied through an access opening in the face of a patient, as it would be for effecting a facelift in a patient. 
           [0018]      FIG. 2  is a vertical sectional view through the instrument of  FIG. 1 , wherein the instrument is shown in the needle withdrawn position, and wherein the various operative components of the instrument are illustrated. 
           [0019]      FIG. 2   a  is a view similar to that of  FIG. 2 , but wherein the suturing needle is shown in the “down” or engaged position, such that the suture carried thereby can be “hooked”. 
           [0020]      FIG. 3   a  is a schematic view of a portion of the instrument of  FIGS. 2 and 2   a , in which the suturing needle is in the “up” position, with the instrument is disposed between inner and outer surfaces between the skin and soft tissue of a patient, with vacuum applied to a cavity at the lower end of the instrument, drawing the skin subcutaneous tissue, fat, fascia or muscle (hereinafter abbreviated STFFM) into the cavity, and with a clamp applied to the outer surface of the skin also effecting engagement of the STFFM that is to be sutured into the cavity, and with the suturing needle in the “up” position. 
           [0021]      FIG. 3   b  is an illustration like that of  FIG. 3   a , wherein an elastomeric sleeve is shown over the cylindrical sleeve and with the STFFM disposed in the cavity. 
           [0022]      FIG. 3   c  is an illustration like that of  FIG. 3   b , but wherein the suturing needle is applied through the cavity, through the STFFM that is to be sutured, carrying the suture therethrough. 
           [0023]      FIG. 3   d  is an illustration like that of  FIG. 3   c , but wherein a manually actuable hook carried at the lower end of the instrument is turned from above, to engage and hook the suture that has been passed through the cavity and engaged STFFM. 
           [0024]      FIG. 3   e  is an illustration like that of  FIG. 3   d , but wherein the clamp is removed, the suturing needle is in the “up” or withdrawn position, and wherein the sutured STFFM is shown attached to the cavity by means of the suture that has been hooked by the hook at the lower end of the instrument, such that, withdrawal of the instrument will withdraw the sutured STFFM in the direction of withdrawal. 
           [0025]      FIG. 4   a  is a vertical sectional split view, fragmentally illustrating a different portion of the operation of the instrument, whereby the surgeon is poised to depress the upper end of the plunger to drive the needle through the STFFM in the cavity, in a downward direction. 
           [0026]      FIG. 4   b  is an illustration like that of  FIGS. 4   a , but wherein the thumb of the surgeon has depressed the plunger completely downwardly, and wherein the needle has passed through the STFFM in the cavity, pulling the suture through the STFFM and cavity along therewith. 
           [0027]      FIG. 4   c  is an illustration like that of  FIGS. 4   a  and  4   b , but wherein the thumb of the surgeon has been withdrawn from the upper end of the plunger, allowing the compression spring to urge the plunger upwardly a distance “D”, whereupon the lower end of the needle is withdrawn upwardly along therewith, such that a loop is formed in the suture that may be grasped by a hook at the lower end of the instrument. 
           [0028]      FIG. 4   d  is an illustration like that of  FIG. 4   c , but wherein the forefinger of the surgeon has been applied to the lever, to retract the lever spring from the position therefore shown in phantom in  FIG. 4   d , to that of the full line position shown in  FIG. 4   d , such that the compression spring can drive the plunger upwardly to the position shown in  FIG. 4   d , leaving the suture secured through the STFFM and cavity of the instrument due to the hooked engagement of the suture at the lower end of  FIG. 4   d.    
           [0029]      FIGS. 4   e ,  4   f ,  4   g  and  4   h  correspond respectively to  FIGS. 4   a ,  4   b ,  4   c  and  4   d , but illustrate an embodiment of the invention where the needle and suture pass outside the cavity, through the STFFM, while a vacuum is drawn on the cavity, retaining the STFFM in the cavity, during passage of the needle through the SSTFM. 
           [0030]      FIG. 5  is a fragmentary view of an alternative embodiment to the instrument of  FIG. 2 . 
           [0031]      FIG. 5   a  is an enlarged fragmentary detailed view of a mechanism for opening and closing the internal toothed forceps of the embodiment of  FIG. 5 . 
           [0032]      FIG. 6  is another alternative embodiment of the instrument of this invention. 
       
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS 
       [0033]    Referring now to the drawings in detail, reference is first made to  FIG. 1 , wherein an instrument  10  is shown in an incision or opening  11  in the skin of a patient P, in accordance with this invention, wherein the instrument  10  is being used during a facelift operation. 
         [0034]    With reference to  FIG. 2 , it will be shown that the instrument  10  includes an insert  12  having first and second ends  13  and  14 , respectively. Above the upper or second end  14  of the insert  12 , there is a manually graspable portion of the instrument  10 , shown in the shape of a spool  15 , which portion  15  of the instrument remains outside the incision or access opening  11  of the patient, during use. Portions of the insert  12  near the lower end are shown broken away for the sake of clarity. The insert  12  includes a hollow sleeve  16  extending downwardly from the lower end of the spool  15 . A suturing needle  17  is slideably carried in the sleeve  16 , for upward and downward movement therein, with the needle  17  carrying a suture  18  at its lower end, which suture  18  enters into the skin access opening  11  with the instrument  10 , as the insert portion  12  of the instrument  10  passes into the opening  11 . The upper end of the needle  17  is carried by a vertically moveable plunger  20 , being mounted to the upper end  21  of the plunger, for movement therewith, as the plunger  20  is engaged by the surgeon for downward movement thereof from the position of the plunger  20  illustrated in  FIG. 2 . 
         [0035]    The insert  12  also carries a vacuum conduit  22  therethrough, extending downwardly from a vacuum line  23  down to a leftwardly opening cavity  24 , as shown in  FIG. 2 . A manually actuable valve  25  is provided for the vacuum line  23 , for on/off actuation by the surgeon. The cavity  24  is comprised of cylindrical sleeve  26  having upper and lower needle-passing holes  27  and  28  respectively in vertical alignment relative to each other, as shown in  FIG. 2 , for passage of the lower end of the needle  17  therethrough, when the needle  17  is actuated by the surgeon to pass through the cavity  24 . 
         [0036]    A rubber, neoprene or similar sealing cylindrical sleeve  30  is applied over the sleeve  26 , with the sleeve  30  having no holes therethrough, to facilitate a sealing adherence to the exterior of the needle  17  after the needle  17  is passed through the cavity  24 , via the openings  27 ,  28 , to facilitate maintaining a vacuum on STFFM that is engaged in the cavity  24 . A hook  31  is shown at the lower end of the insert  12 , carried by a vertically disposed rod  32 , which rod  32  extends from the first end  13  of the insert  12 , up through the insert (not shown), passing through the instrument  10 , to emerge at the upper end thereof, and terminating in an actuation knob  32 . 
         [0037]    With reference to  FIG. 2 , it will be seen that a safety cap  19  is provided, carried in snap-on, snap-off relation by bosses  19 ′,  19 ″, that, in turn, are carried by the insert  12  and sleeve  26 , with the boss  19 ″ projecting through the sealing cylindrical sleeve  30 , as shown, such that the cap  19  provides protection for the hook  31  as shown in  FIG. 2 , as well as providing protection for the needle  17  after it is inserted through the cavity  24 . Additionally, the removable cap  19  protects the patient when the instrument  10  is inserted beneath the skin of a patient as described below with respect to  FIGS. 3   a - e,    FIGS. 4   a - d  and  FIG. 6 . Thus, the patient is protected from the needle stroke and the loop of the suture  18  is protected from being distorted by tissue engagement. Additionally, the use of the cap  19  facilitates retrieval of the suture via the hook. Additionally, accidental breakage of the needle  17  is minimized. 
         [0038]    The safety cap  19  illustrated in  FIG. 2 , is not specifically illustrated in  FIG. 3   a - e,    FIG. 4   a - d  and  FIGS. 5 and 5   a , in the interest of clarity, for emphasizing other components of the instruments of this invention, but it will be understand that the safety cap  19  is similarly carried at the lower end of the instruments of these other above-mentioned Figures. 
         [0039]    An external clamp device  35 , is shown in  FIG. 2 , pivotally mounted at  36 , to a boss  37  at the upper end of the insert  12 , below the spool  15 . The clamp device  35  includes a clamp rod  38  carried by the boss  37  at its upper end, and which carries a threaded member  40  at its lower end. The member  40  has an exterior skin-engaging contact  41 , preferably of a soft material such as rubber, neoprene or the like, at its right end as shown in  FIG. 2 , and a manual actuation knob  42  at its left end. The rod  38  is pivotally moveable leftward from its position shown in  FIG. 2  about pivot  36 , but can be locked in the position shown in  FIG. 2  via any suitable locking means, such as by means of a clasp  43  in hooked engagement over a keeper  44  carried by the boss  37 , as shown. 
         [0040]    A helical compression spring  45  is shown, disposed about the upper end of the needle  17 , inside the spool  15 , in seated engagement against the lower end  47  of the spool  15 , and pressing against lower surface  28  of the upper end  21  of the plunger  20 , although the intermediate portions of the spring  45  are shown broken away for the sake of clarity. The effect of the spring  45  is to urge the plunger  20  toward its upper position as shown in  FIG. 2 . When the plunger  20  is engaged at its upper exterior end  21  by the surgeon, for moving the needle  17  downwardly from the position shown in  FIG. 2 , to pass through the cavity  24  as aforesaid, the leftward protrusion  50  thereof, at the lower end of the plunger  20  can move vertically downwardly, sliding in keyway  51 . As the protrusion  50  moves downward, it will engage the leaf spring  52  mounted on support member  53  and moves the spring  52  leftwardly as shown in the phantom position therefore illustrated in  FIG. 4   a.    
         [0041]    With reference to  FIG. 2   a , it will be seen that the plunger  20  has been engaged at its upper end  21  and moved vertically downwardly, compressing the compression spring  45 , lowering the needle  17  to its downward position as shown in  FIG. 2   a , with the lower end of the needle  17  and the suture  18  carried thereby in engagement through the cavity  24 , having passed through holes  27 ,  28  (not shown in  FIG. 2   a ), and with the sealing sleeve  30  being in sealed engagement against the exterior of the needle  24 . The hook  31  carried by the rod  32 , at the lower end of the insert  12 , is shown in  FIG. 2   a  as being in the hooked position, engaging the suture  18  upon the knob  33  at the upper end of the rod  32  having been manually engaged and turned in the direction of the arrow  60  shown in  FIG. 2   a.    
         [0042]    Referring now to  FIGS. 3   a - 3   e , the use of the instrument of this invention will now be discussed. 
         [0043]    In  FIG. 3   a  the instrument  10  is shown, with the upper end, including the plunger  20  thereof being in phantom. The needle  17  which carries the suture  18  is shown, fragmentally illustrated, poised to descend through holes  27  and  28  of the cavity  24 . The elastomeric sleeve  30  is shown to the left of the cavity  24 , over which it is applied prior to insertion of the insert  12  into the incision  11  on the face of the patient P. In the illustration of  FIG. 3   a , the clamp device  35  is shown in the outward position, with the clasp  43  unclasped from the keeper  44 , in order to facilitate insertion of the insert  12  into the skin opening  11 . 
         [0044]    With reference now to  FIG. 3   b , the insert  12  is shown inserted through the incision  11 , between outer and inner skin layers  65 ,  66  respectively, with the right surface  67  of layer  66  representing the STFFM surface inside the patient P (such as inside the mouth of the patient), and with the left-most surface  68  of the skin layer  65  representing the outer surface of the face of the patient P. In the illustration of  FIG. 3   b , the elastomeric sleeve  30  is shown applied over the cylindrical sleeve  26 , closing the holes  27 ,  28  thereof. 
         [0045]    At this point, the valve  25  shown in  FIG. 2  is actuated to provide vacuum via line  23 , down through the vacuum delivery conduit  22  of  FIG. 2 , to draw a partial vacuum on the cavity  24 , to urge the STFFM  70  further into the cavity  24 , to the right of the vertical axis through the holes  27 ,  28 . Then, the plunger  20  is actuated against the force of the spring  45 , through engagement generally by the thumb of the surgeon, against the surface  21 , such that the plunger  20  moves downwardly, bringing the needle  17  and its carried suture  18  downwardly, piercing the elastomeric sleeve  30 , such the needle passes through the openings  27 ,  28 , piercing the STFFM  70 , as shown in  FIG. 3   c.    
         [0046]    Because vacuum may be compromised when the needle pierces the sleeve  30 , a clamping device  35  is also provided. The clamping device  35  is shown locked in the face-engaging position, with the clasp  43  locked against the keeper  44 , such that the threaded member  40  may be rightwardly urged, by manually engaging the knob  42  and rotating the threaded member  40  in the threaded lower end of the member  35 , such that its contact  41  engages the other surface  68  of the face, pushing the portion  70  of STFFM to the right thereof, into the cavity  24 , in airtight engagement against the left-most end of the elastomeric sleeve  30 . The clamping device  35  thus retains the status quo position of STFFM portion  70  in cavity  24  after vacuum is broken as the needle  17  pierces sleeve  30 , in order to avoid STFFM movement as the needle  17  enters STFFM portion  70 , that might otherwise result in needle breakage if the skin portion  70  moved while the needle is in engagement with the skin. 
         [0047]    With reference now to  FIG. 3   d , it will be seen that the knob  33  is rotated in the direction of the arrow  60 , such that the rod  32  connected to the knob  33  is likewise rotated, to turn the hook  31  from the non-engaged position thereof illustrated in  FIG. 3   c , to the suture-engaged position of  FIG. 3   d , in which it engages the loop of suture  18  that extends below the sleeve  30 . 
         [0048]    Then, as can be seen from  FIG. 3   e , the valve  20  can be actuated from outside by the surgeon, such that the vacuum is released, and the device  35  may be released by release of the clasp  43  from the keeper  44 , and the suture-threaded portion of the STFFM  70  will remain connected to the lower end  13  of the insert, because the hook  31  remains in hooked relation to the loop of suture  18  shown beneath the sleeve  30 , extending through the holes  27  and  28  even as the needle  17  is withdrawn from the position of the needle  17  shown in  FIG. 3   d , to its position as shown in  FIG. 3   e . Thus, the zone  70  of STFFM on the inside of outer STFFM layer  65 , yet outside layer  66 , remains connected to the lower end of the insert  10 , for withdrawal therewith, when the insert  12  is raised in the direction of the arrow  80  of  FIG. 3   e , for removal of the insert  12  from the skin opening  11 , whereby the facelift is effected. 
         [0049]    With reference now to  FIGS. 4   a - 4   d , some of the finer points with respect to the formation of a loop for the suture  18 , whereby the same may be engaged by a hook  31 , will now be discussed. 
         [0050]    With reference to  FIG. 4   a , it will be seen that the thumb “T” of the surgeon engages surface  21  of the plunger  20 , driving the same downwardly, such that the leading protrusion  50  thereof, at the lower left end of the plunger  20  engages against and cams against the curved surface of the leaf spring  52 , moving the same from the full line position therefore illustrated in  FIG. 4   a , to the phantom position therefore illustrated in  FIG. 4   a , against the action of compression spring  45 , to drive the needle  17  downwardly, piercing the elastomeric sleeve  30  as described above, whereby the needle  17  may pierce the STFFM layer  65 , carrying the suture  18  therewith. 
         [0051]    Thus, the plunger  20  is moved from its position shown if  FIG. 4   a , to its position shown in  FIG. 4   b , in which the STFFM layer  65  is pierced, and in which the plunger  20  is in its downward position, with the leaf spring  52  having returned to its full line position from the phantom position therefore illustrated in  FIG. 4   a.    
         [0052]    With reference now to  FIG. 4   c , it will be seen that the thumb “T” of the surgeon has been removed, such that the compression spring  45  can urge the plunger  20  upwardly, such that the upper end of the protrusion  50  of the plunger  20  engages against the lower edge of the leaf spring  52 , which limits the upper movement of the plunger  20  to an amount “D” as shown in  FIG. 4   c , whereby the needle  17  is carried upwardly by the plunger  20  the same amount “D”, as the needle  17  moves from its phantom position therefore illustrated in  FIG. 4   c , to the full line position therefore illustrated in  FIG. 4   c , such that the suture  18  which is frictionally engaged with the STFFM layer  65  and elastomeric sleeve  30  against upward movement with the needle  18 , forms a loop at its lower end as shown in  FIG. 4   c.    
         [0053]    Then, the knob  33  is actuated as described above with respect to  FIG. 3   e , whereby the hook  31  engages the loop of the suture  18 . 
         [0054]    Next, the lever  54  is engaged by the forefinger “F” of the surgeon, depressing the same from its phantom position therefore illustrated in  FIG. 4   d , to its full line position therefore, whereby the short leg  39  of the lever pivots about the pivot point  55 , to engage the cam  49  carried by the leaf spring  52 , to cam the spring  52  leftwardly, from the full line position therefore illustrated in  FIG. 4   c , to the full line position illustrated therefore in  FIG. 4   d , to clear the passageway  51 , such that the compression spring  45  may drive the plunger  20  upwardly, to return to its position shown in  FIG. 4   a , while withdrawing the needle  17  upwardly, out of the cavity  24 , and removed from the skin layer  65  disposed therein, but with the suture  18  remaining in position through the skin layer  65 , due to it being hooked by the hook  31  at its lower end as shown in  FIG. 4   d.    
         [0055]    It will thus be seen that the vacuum lift feature of this invention enables the surgeon to engage STFFM internally of the patient, at a location on the STFFM that optimizes the engagement of the same with the needle and thread, with the ability to vary the precise location of engagement of the STFFM with the needle and thread for optimizing the lift of the STFFM. Then, in the case of, for example, a facelift, if the optimum engagement of STFFM occurs on one side of the face, the same, or mirror imaged location on the opposite side of the face may be engaged, with precision, to balance the lift effects on each side. 
         [0056]    With specific reference now to  FIG. 4   e , it will be noted that the partial vacuum that is drawn via line  23  draws a vacuum on the cavity  24 ′, in the same manner as the vacuum is drawn in the embodiment of  FIG. 4   a , and the STFFM  65 ′ is drawn into that cavity  24 ′, such that a right-most portion of the STFFM is drawn into the cylindrical member  30 ′, in much the same manner as the STFFM  70  is drawn into the cylindrical sleeve  26  as shown in  FIG. 3   d.    
         [0057]    Then, as illustrated in  FIG. 4   f , the needle  17  carrying a suture  18 , passes through the STFFM  65 ′ while the STFFM is held via the vacuum, in the cavity  24 ′. 
         [0058]    Thereafter, the needle  17  is partially withdrawn as shown in  FIG. 4   g , in much the same manner as the needle is partially withdrawn as shown in the embodiment of  FIG. 4   c  for engagement of the suture  18  by the hook  31 , as described above with reference to  FIG. 4   c.    
         [0059]    As shown in  FIG. 4   h , the needle  17  is withdrawn vertically upwardly, leaving the suture  18  threaded through the STFFM, and having its lower loop captured by the hook  31 , after which the compression spring  45  may drive the plunger  20  upwardly, to return to its position shown in  FIG. 4   e . It will be noted that for the illustrations of  FIGS. 4   e ,  4   f ,  4   g  and  4   h , like components are numbered as their counterpart components are numbered in  FIGS. 4   a ,  4   b ,  4   c  and  4   d.    
         [0060]    It will also be noted that in the illustrations of  FIGS. 4   e ,  4   f ,  4   g  and  4   h , the cavity  24 ′ is not illustrated as protruding leftwardly the same amount as the cavities  24  illustrated in  FIGS. 4   a ,  4   b ,  4   c  and  4   d , in that in the embodiment of  FIGS. 4   e ,  4   f ,  4   g  and  4   h , the cylindrical member  30 ′ likewise does not protrude leftwardly the same amount as does its counterpart in  FIGS. 4   a ,  4   b ,  4   c  and  4   d , but, it will be understood, that the amount of such protrusion can be varied, as long as the size of the cavity  24 ′ is sufficient to vacuum-engage the STFFM therein, while maintaining a partial vacuum seal against the cylindrical member  30 ′, to enable penetration of the SSTFM by the needle  17 , for suturing the same as described above. 
         [0061]    With specific reference now to  FIG. 5 , an alternative embodiment for the instrument  110  is illustrated in which in some situations, application of vacuum may not be necessary, by the use of a forceps, whereby a needle  117  is disposed within a sleeve  116 , to be driven downwardly by a plunger (not shown) similar to the embodiment of  FIG. 2 , with the needle  117  carrying a suture  118 . An external clamping device  135  similar to that of  FIG. 2  is likewise carried by the instrument  110 , having a clamp rod  138  that, in turn, carries a manual actuation knob  142  that is adapted to turn a threaded member  140 , such that an exterior skin-engaging contact  141  is adapted to make contact with external skin  165 , to urge the same into a cavity  124  that exists between a pair of cooperating toothed forceps  124 ,  125 , mounted about a common pivot  126 , which pivot  126 , is, in turn, carried by a generally vertically disposed rod  112  that comprises part of the instrument  110 . Thus, the toothed forceps  124 ,  125 , may be lowered between skin layers of a face or the like similarly to the manner in which the insert  12  of  FIG. 2  is used. 
         [0062]    After the forceps  124 ,  125 , are in place between inner and outer layers, the skin-contacting contact  141  will urge the skin  165  between the teeth  144 ,  145  of the forceps  124 ,  125 , an amount such that the STFFM becomes disposed between the needle openings  127 ,  128  of the pincers  124 ,  125 , such that downward movement of the needle  117  will carry the suture  118  through the openings  127 ,  128 , whereupon the rod  113  that carries the hook  131  may be lowered to a position below the pincer  125 , such that the hook  131  can engage a loop of the suture  118  in a manner similar to that described above with respect to  FIGS. 4   c  and  4   d.    
         [0063]    It will be apparent that the rod  112  that carries the forceps  124 ,  125 , may be unitary with the insert  110 , even though the components of  FIG. 5  are only fragmentally illustrated for the sake of clarity. 
         [0064]    Also, with reference to  FIG. 5   a , an enlarged detail view of the forceps  124 ,  125  is fragmentally illustrated, including a device for controllably opening and closing the forceps  124 ,  125 , comprising a threaded rod  170 , carried for rotational movement from above (similar to that of the knob  33  of  FIG. 3   e ), such that threads of the threaded rod  170  may be in engagement with comparably threaded portions of the forceps  124 ,  125 , as shown in phantom at  171 ,  172 , to urge the forceps  124 ,  125 , more closely together, or farther apart, with such urging together being against the action of a leaf spring  173  disposed there between. It will be apparent that various other techniques for opening and closing the forceps  124 ,  125  may likewise be used, instead of the mechanism shown in  FIG. 5   a.    
         [0065]    With reference now to  FIG. 6 , it will be seen that another alternative embodiment of the invention is disclosed, in which the needle  217  is essentially U-shaped at its lower end, adapted for movement upwardly in the direction of the arrow  219 , to enter the openings  228 ,  227 , such that the surgeon can manually recover the suture  218  with either a forceps (not shown), or a hook  231  carried by a rod  232 , by directly observing the suture endoscopically. It will be understood that a protective chamber or cap like that  19  (not shown) of  FIG. 2 , may also be utilized to protect the needle and the patient at the lower end of the embodiment of  FIG. 6 . Such a chamber or safety cap is not shown in  FIG. 6 , for the sake of clarity of the rest of the items illustrated. It will further be understood that the various other components of the device of  FIG. 6 , numbered in the  200  series, correspond to similarly numbered items in  FIGS. 2 and 2   a  carrying double digit numbers. Thus, item  212  of  FIG. 6  corresponds to item  12  of  FIGS. 2 and 2   a ; item  235  of  FIG. 6  corresponds to item  35  of  FIGS. 2 and 2   a ; chamber  224  of  FIG. 6  corresponds to chamber  24  of  FIGS. 2 and 2   a , etc. . . . , such that redundant explanation of the operation of similar components of  FIG. 6  to those of  FIGS. 2 and 2   a  need not herein be repeated. 
         [0066]    It will thus be seen that, while the operation of the instrument  10 ,  110  or  210  of this invention has been described above, by way of example, as being used to effect a facelift, the instrument  10 ,  110  or  210  can be used for various other purposes, where it is desired to engage STFFM inside an outer surface thereof, but outside an inner surface thereof, and to move that STFFM from one location to another, whether such lifting is upwardly, or in any other direction. Thus, the instrument of this invention may be used to effect brow surgery, a breast lift, a thigh lift, an abdominal skin lift, or any other shifting of STFFM from one location to another. 
         [0067]    It will be understood that within the scope of this invention, various details may be modified, all within the spirit and scope of the invention as defined by the appended claims. For example, the threaded member  40  is shown by way of illustration only, in that any other contact member for engaging the outside surface of skin, to facilitate the placement of that portion of the STFFM that is to be sutured, may be effected. Accordingly, while a device of the type  35  that is shown for carrying the threaded member  40  may be of the type shown, various other techniques for engaging the outer surface  68  of skin may suffice. Similarly, while a clasp  43  may be used for locking the device  35  in a skin-contacting position as shown in  FIG. 3   d , any other form of locking device may likewise be utilized. Similarly, while an elastomeric cylindrical seal such as that  30  is shown for facilitating the maintenance of a vacuum around the outer surface of the needle  17  is shown as a preferred technique, various other vacuum-assuring techniques may alternatively be utilized. Also, while a hook such as that  31 , actuable from a member such as that  33  is described as a means for securing the sutured STFFM  70  to the lower end  13  of the insert, other securement means may likewise be utilized. Furthermore, while the lever arrangement  54  and leaf spring  52  is shown as a means for holding the plunger  20  in the “down” position, various other techniques could likewise be used. Also, while the spring  45  is shown in the position for maintaining the plunger up, except when it is to be brought down against the force of the spring  45 , the converse arrangement could be used, in which the spring generally maintains the plunger downward, until it is pulled upwardly. 
         [0068]    It will be apparent from the foregoing that various other modifications and variations may be made in the instrument of this invention, all within the spirit and scope of the invention as defined in the appended claims.