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Thread-Lift Sutures: Still in the Lift? A Systematic Review of the Literature

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Background: In 2006, Villa et al. published a review article concerning the use of thread-lift sutures and concluded that the technique was still in its infancy but had great potential to become a useful and effective procedure for nonsurgical lifting of sagged facial tissues. As 11 years have passed, the authors now performed again a systematic review to determine the real scientific current state of the art on the use of thread-lift sutures. Methods: A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the PubMed database and using the Medical Subject Headings search term "Rhytidoplasty." "Rhytidoplasty" and the following entry terms were included by this Medical Subject Headings term: "facelift," "facelifts," "face Lift," "Face Lifts," "Lift," "Face," "Lifts," "Platysmotomy," "Platysmotomies," "Rhytidectomy," "Rhytidectomies," "Platysmaplasty," "and "Platysmaplasties." The Medical Subject Headings term "Rhytidoplasty" was combined with the following search terms: "Barbed suture," "Thread lift," "APTOS," "Suture suspension," "Percutaneous," and "Silhouette suture." RefWorks was used to filter duplicates. Three of the authors (H.A.G., B.C., and B.L.) performed the search independently. Results: The initial search with all search terms resulted in 188 articles. After filtering the duplicates and the articles about open procedures, a total of 41 articles remained. Of these, the review articles, case reports, and letters to the editor were subsequently excluded, as were reports dealing with nonbarbed sutures, such as Vicryl and Prolene with Gore-Tex. This resulted in a total of 12 articles, seven additional articles since the five articles reviewed by Villa et al. Conclusions: The authors' review demonstrated that, within the past decade, little or no substantial evidence has been added to the peer-reviewed literature to support or sustain the promising statement about thread-lift sutures as made by Villa et al. in 2006 in terms of efficacy or safety. All included literature in the authors' review, except two studies, demonstrated at best a very limited durability of the lifting effect. The two positive studies were sponsored by the companies that manufacture the thread-lift sutures.
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www.PRSJournal.com 341e
Since the introduction of thread-lift sutures,
its application has gradually spread among
many cosmetic medical specialists (such as
plastic surgeons and maxillofacial surgeons) and
cosmetic doctors (medical doctors and dentists
specialized in noninvasive aesthetic treatments
such as botulinum toxin type A and filler injec-
tions), with the main indication of lifting sagged
tissues by means of a minimally invasive closed
procedure. Its application is claimed to be easy
after proper training, and it is suggested to be a
good alternative for surgical lifts because it is a
significantly less invasive procedure. Many col-
leagues used the technique in the early 1990s
but stopped doing so because of disappointing
results. Currently, more and more cosmetic doc-
tors offer the procedure; this is the next group
of cosmetic treatment providers that will experi-
ence the true value of thread-lift sutures. The cos-
metic industry has flooded the market with a vast
Disclosure: The authors have no financial interest
to declare in relation to the content of this article. No
funding was received.
Copyright © 2018 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000004101
Haydar Aslan Gülbitti, M.D.
Britt Colebunders, M.D.
Ali Pirayesh, M.D.
Dario Bertossi, M.D.
Berend van der Lei, M.D.,
Ph.D.
Heerenveen, Zwolle, Amsterdam, and
Groningen, The Netherlands; Kortrijk,
Belgium; and Verona, Italy
Background: In 2006, Villa et al. published a review article concerning the use
of thread-lift sutures and concluded that the technique was still in its infancy
but had great potential to become a useful and effective procedure for nonsur-
gical lifting of sagged facial tissues. As 11 years have passed, the authors now
performed again a systematic review to determine the real scientific current
state of the art on the use of thread-lift sutures.
Methods: A systematic review was performed according to Preferred Reporting
Items for Systematic Reviews and Meta-Analyses guidelines using the PubMed
database and using the Medical Subject Headings search term “Rhytidoplasty.”
“Rhytidoplasty” and the following entry terms were included by this Medical
Subject Headings term: “facelift,” “facelifts,” “face Lift,” “Face Lifts,” “Lift,”
“Face,” “Lifts,” “Platysmotomy,” “Platysmotomies,” “Rhytidectomy,” “Rhytidecto-
mies,” “Platysmaplasty,” “and “Platysmaplasties.” The Medical Subject Headings
term “Rhytidoplasty” was combined with the following search terms: “Barbed
suture,” “Thread lift,” “APTOS,” “Suture suspension,” “Percutaneous,” and “Sil-
houette suture.” RefWorks was used to filter duplicates. Three of the authors
(H.A.G., B.C., and B.L.) performed the search independently.
Results: The initial search with all search terms resulted in 188 articles. After
filtering the duplicates and the articles about open procedures, a total of 41
articles remained. Of these, the review articles, case reports, and letters to the
editor were subsequently excluded, as were reports dealing with nonbarbed
sutures, such as Vicryl and Prolene with Gore-Tex. This resulted in a total of 12
articles, seven additional articles since the five articles reviewed by Villa et al.
Conclusions: The authors’ review demonstrated that, within the past decade,
little or no substantial evidence has been added to the peer-reviewed literature
to support or sustain the promising statement about thread-lift sutures as made
by Villa et al. in 2006 in terms of efficacy or safety. All included literature in the
authors’ review, except two studies, demonstrated at best a very limited durability
of the lifting effect. The two positive studies were sponsored by the companies
that manufacture the thread-lift sutures. (Plast. Reconstr. Surg. 141: 341e, 2018.)
From the Department of Plastic Surgery, University of Gron-
ingen, University Medical Centre Groningen; Amsterdam
Plastic Surgery; and Bergman Clinics; the Department of
Plastic Surgery, AZ Groeninge; and the Department of Max-
illofacial Surgery, University of Verona.
Received for publication July 19, 2017; accepted October 4,
2017.
Thread-Lift Sutures: Still in the Lift? A Systematic
Review of the Literature
COSMETIC
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
342e
Plastic and Reconstructive Surgery • March 2018
array of different types of so-called thread-lifting
sutures. Substantial amounts of marketing budget
have been allocated by these companies to “train”
physicians in this procedure. These commercial
incentives in combination with enthusiastic cos-
metic professionals are mainly responsible for the
extensive spread of this supposed minimally inva-
sive lifting procedure.
In 2006, Villa et al. published a review arti-
cle concerning the use of thread-lift sutures
for midface elevation.1 The authors concluded
that the technique was still in its infancy, but
that it had the potential to become a useful and
effective procedure as further innovations were
made. As 11 years have passed, and based on
personal experience with thread-lift sutures,
we were curious about the real scientific state
of the art on the use of thread-lift sutures and
therefore performed a systematic review on this
topic.
PATIENTS AND METHODS
A systematic review was performed accord-
ing to Preferred Reporting Items for Systematic
Reviews and Meta-Analyses guidelines using the
PubMed database and the Medical Subject Head-
ings search term “Rhytidoplasty.” “Rhytidoplasty”
is defined as plastic surgery performed, usually
by excision of skin, for the elimination of wrin-
kles from the skin. The term was introduced in
1989. The following entry terms are included by
this Medical Subject Headings term: “facelift,”
“facelifts,” “face Lift,” “Face Lifts,” “Lift,” “Face,”
“Lifts,” “Platysmotomy,” “Platysmotomies,” “Rhyt-
idectomy,” “Rhytidectomies,” “Platysmaplasty,”
and “Platysmaplasties.”
The Medical Subject Headings term “Rhyti-
doplasty” was combined with the following search
terms “barbed suture,” “Thread lift,” “APTOS,”
“Suture suspension,” “Percutaneous,” and “Sil-
houette suture.” RefWorks (ProQuest, Ann Arbor,
Mich.) was used to filter duplicates. Three of the
authors (H.A.G., B.C., and B.L.) performed the
search independently.
As we focused on closed procedures, we elimi-
nated any article describing open procedures in
combination with thread-lift sutures during a first
search. Subsequently, all review articles, technical
reports, case reports, and letters to the editor were
withdrawn in a second search. Eventually, all arti-
cles dealing with nonbarbed sutures, such as Vic-
ryl (Ethicon, Inc., Somerville, N.J.) and Prolene
(Ethicon) with Gore-Tex (W. L. Gore & Associ-
ates, Flagstaff, Ariz.), were excluded.
We reviewed the literature to evaluate the
same clinical parameters as reported in the review
article by Villa et al. 11 years ago: (1) the type of
suture, (2) the efficacy and longevity of the effect,
and (3) the adverse events. However, we did
not limit our search to midface elevation alone;
instead, we included all articles on soft-tissue lift-
ing in the face.
RESULTS
The initial search with all search terms
resulted in 188 articles. After filtering the dupli-
cates and the articles about open procedures, a
total of 41 articles remained (Fig. 1). Of these, the
review articles, case reports, and letters to the edi-
tor were subsequently excluded. This resulted in
24 articles to be included in further search and
review (Fig. 2). During a more detailed review of
these articles, any study that dealt with nonbarbed
sutures, such as Vicryl on a Gore-Tex patch, was
also eliminated. Also, articles that did not men-
tion a follow-up time were filtered out. Finally,
12 articles were considered for use in this review,
of which five dated from before 2006 and were
already discussed in the review article by Villa et
al.1 As it was not our intention to replicate the
findings reported by Villa et al., we focused on
the most recent seven additional included articles
(Table 1).2–8
Type of Suture
Four of five studies reviewed by Villa et al.
used Aptos (Aptos International, Tbilis, Geor-
gia) threads for closed suspension.1 These Aptos
threads are no longer described in recent studies.
Instead, Contour Threads (Angiotech Pharma-
ceuticals, Inc., Vancouver, British Columbia, Can-
ada) are being described (in four of six studies).
Aptos Threads and Woffles Threads
The Aptos threads were described by Sula-
manidze et al. in 2002 and are made of 2-0 poly-
propylene line with dents provided during the
manufacturing process, thus creating slant edges
with sharp ends.9 Woffles threads were described
by Wu.10 We did not find any recent literature
describing long-term results of these sutures.
Contour Threads (Nonresorbable)
Contour Threads were approved by the U.S.
Food and Drug Administration in October of
2004. They consist of a 25-cm length of 2-0 poly-
propylene suture with a central 10-cm segment of
50 unidirectional helicoidally configured barbs
(Surgical Specialties Corp., Reading, Pa.).
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 141, Number 3 • Review of Thread-Lift Sutures
343e
Multianchor Suspension Suture (Resorbable)
Eremia and Willoughby used a multianchor
suspension suture assembled from 2-0 absorbable
monofilament material, with five to nine equally
spaced knots through which are secured 7- to
9-mm bits of similar suture material.2
Silhouette Soft
Poly-l-lactic acid, the principal component of
Silhouette Soft (Sinclair Pharma, London, United
Kingdom), is a well-known polymer that has been
used for many years in a large number of biomedi-
cal and pharmaceutical applications. It is because
Fig. 1. Initial search.
Fig. 2. Detailed search.
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
344e
Plastic and Reconstructive Surgery • March 2018
Table 1. Overview of the Search Results*
Reference
Specialty of the
Author Device No. of Patients Follow-Up Evaluation Results Complications Disclosures
Eremia and
Willoughby,
20062
Dermatologist Multianchor
suspen-
sion
suture
20 patients of which
14 underwent
pure, “no-
skin-excision,”
suspension lifts
6–12 mo Preoperative and
postoperative
photographs
With pure suspension
lift; by 6 mo, correc-
tion started to fade; by
12 mo, 100% of initial
correction for jowls,
and 80 to 100% for
midface, appeared lost;
recovery time was 2–4
days
No significant
complication Nondisclosure
Kaminer
et al., 20083Dermatologist Contour
Threads 20 patients were
mailed, 12
replied
Minimum
6 mo Anonymous
satisfaction survey Satisfaction, 6.9; over-
all improvement, 4.6
(scale, 1–10)
Bruising, swelling,
pinching Grant from
Angiotech
(company
makes Con-
tour Threads)
Abraham
et al., 20094Otolaryngologist Contour
Threads 33 patients, of which
10 underwent
thread lift alone;
23 in combination
with other pro-
cedure; control
group
12–31 mo Blinded surgeon
scoring an
aesthetic grading
scale
Overall aesthetic
improvement 0.2–0.5,
which implicates
minimal improvement
(scale, 0–3)
Skin dimpling,
visible knots Dr. Williams is
a shareholder
in the New
England Laser
and Cosmetic
Surgery
Center
Garvey et al.,
20095Plastic surgeon Contour
Threads 72 patients,
of which 55
underwent a
pure closed
procedure
8.4 mo Chart review 30 of the 72 patients
(42.3%) underwent
some form of revision
surgery at an average of
8.4 mo
Swelling, ecchy-
mosis, infection,
thread extru-
sion, palpable
threads, contour
irregularity, and
recurrent laxity
Unknown
Rachel et al.,
20106Plastic surgeon Contour
Threads 29 patients,
of which 18
underwent a
pure closed
procedure
1–25 mo
(average,
12 mo)
Nonblinded review
of preoperative
and postoperative
photographs by
surgeons and
patients
50% recurrence of lax-
ity within 6 mo; 14%
already in the first 8 wk;
17 patients required
second procedure dur-
ing follow-up period
20 patients (69%):
intractable pain,
dimpling, visible
and palpable
thread, thread
extrusion, par-
esthesia, foreign
body reaction
Nondisclosure
de Benito
et al., 20117Maxillofacial
surgeon Silhouette
Sutures 316 patients, 22 of
which underwent
a combined mid-
face suture lift
and endoscopic
forehead lift or
upper and/or
lower blepharo-
plasty or neck lift
Maximum
3 yr
( average
18 mo)
Preoperative and
postoperative
photographs
The results are relatively
long-lasting with high
levels of satisfaction
among patients and
surgeons
42 patients
(13.3%): moder-
ate pain in the
temporal area
(7%), visible
dermal pinching
(3.5%), hema-
toma in the
temporal area
(1.3%), asym-
metry (0.6%),
suture palpabil-
ity (0.3%)
Dr. de Benito
received
consulting
fees from
Silhouette Lift
company
(Continued)
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 141, Number 3 • Review of Thread-Lift Sutures
345e
this polymer is particularly biocompatible in the
human body, and also completely biodegrad-
able, that such applications have been developed.
De Benito et al. used Silhouette sutures.7 They
consist of a 37.3-cm length of 3-0 polypropylene
suture with a central 8-cm segment of nine knots
at approximately 10-mm intervals. Each knot is
intercalated with an absorbable cone of poly-
l-lactic acid, making up a series of eight engaging
elements.
Polydioxanone Threads (Resorbable)
Suh et al. used resorbable knotless polydioxa-
none threads.8 Cog polydioxanone threads have
barbs, which stick to tissues when inserted and
result in lifting. Depending on the direction of
the spikes, cog polydioxanone threads are cat-
egorized as unidirectional, bidirectional, or
multidirectional.
Efficacy and Longevity
Eremia and Willoughby stated that correction
started to fade by 6 months after a pure suspen-
sion lift.2 By 12 months, 100 percent of the ini-
tial correction for jowls and 80 to 100 percent for
midface appeared lost. Kaminer et al., in contrast,
showed satisfaction scores of 6.9 on a scale of 1
to 10 and overall improvement scores of 4.6 on
an anonymous satisfaction survey.3 Abraham et al.
showed only a minimal overall aesthetic improve-
ment scored by blinded surgeons on an aesthetic
grading scale.4 In a study by Garvey et al., 30 of
72 patients (42.3 percent) underwent some form
of revision surgery at an average of 8.4 months.5
Recurrent laxity was considered as an adverse
event by this study group.
De Benito et al., however, showed good results
with high patient satisfaction over a mean follow-
up period of 18 months.7 All of the patients had
stable results during the follow-up period.
Rachel et al. showed 50 percent recurrence
of laxity within 6 months; 14 percent had already
occurred in the first 8 weeks. Seventeen patients
required a second procedure during the follow-
up period.6 Suh et al. found 45 percent of patients
with a fair or poor lifting effect.8
Adverse Events
Swelling and bruising were identified as the
most frequent complications.3,5,7,8 Three studies
described visible and/or palpable threads.3,4,6,7
Skin dimpling and contour irregularities were
noted as well.4–7 Two studies showed thread extru-
sion.5,6 Rachel et al. identified three additional
complications (i.e., intractable pain, paresthesia,
Suh et al.,
20158Dermatologist Knotless
polydi-
oxanone
threads
(absorb-
able)
31 patients 24 wk Self-evaluated
result: physician
assessment
( texture
improvement
and lifting effect);
patient satisfaction
27 patients (87%), the
self-evaluated result was
considered satisfactory,
including 19 patients
(61%) with excellent
and 8 (21%) with good
results; the result was
considered unsatisfac-
tory for the remaining 4
patients (13%); texture
improvement was clas-
sified as excellent for
13 (41.9%), good for
9 (29.0%), fair for 8
(25.8%), and poor for
1 (3.2%) patient(s);
lifting was evaluated as
excellent for 11 (35.5%),
good for 6 (19.4%), and
fair or poor for 14 (45%)
The most frequent
complication
was bruising,
which occurred
in 29 patients
(93.5%); mild
postprocedure
swelling was
observed in
28 patients
(90.3%); mild
asymmetry was
observed in 2
patients (6.5%)
No significant
interest with
commercial
supporters
*Compared with the results by Villa et al. Seven additional articles were added.
Table 1. Continued
Reference
Specialty of the
Author Device No. of Patients Follow-Up Evaluation Results Complications Disclosures
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
346e
Plastic and Reconstructive Surgery • March 2018
and foreign body reaction).6 Other complications
described were infection and mild asymmetry.5,7,8
Serious adverse events, including injury to the
facial nerve, have not been reported.
DISCUSSION
This systematic review regarding the use of
thread-lift sutures for closed minimally invasive
lifting procedures in the face clearly demonstrates
that, despite promising results suggested by pre-
liminary results in the past, there is no substantial
scientific evidence that thread-lift sutures have a
long-lasting effect. Eleven years ago, Villa et al.
concluded that the thread-lift suture lift technique
was still in its infancy but suggested that it had the
potential to become a very useful and effective
clinical tool as further innovations were made.1
However, they also stated that future research
concerning the thread-lift suture should consider
objective, standardized photographic analysis of
facial suspension at fixed intervals postoperatively
in a double-blinded fashion.
Unfortunately, we have found only one such study
using a control group for evaluation and a blinded
surgeon scoring an aesthetic grading scale after the
use of thread-lift sutures.4 The authors of this study
concluded that the thread-lift provides only limited
short-term improvement that may be largely attribut-
able to postprocedural edema and inflammation.
Most other studies demonstrated only a lim-
ited effect and/or limited longevity. A study by
Suh et al. showed that the thread lift was effec-
tive for uneven facial textures, slack midface, and
minimal to moderate jowls in selected patients.8
However, the lifting effect was evaluated as fair to
poor in 45 percent of patients. Eremia and Wil-
loughby showed that correction started to fade by
6 months, and 80 to 100 percent of the correction
appeared lost by 12 months.2 Garvey et al. found a
high rate of revision procedures following a Con-
tour Thread lift; in addition, the time to revision
was found to be short.5 They concluded that the
results achieved by the Contour Thread lift were
subtle and short-lived and advocate that patients
be educated about these limitations. A study by
Rachel et al. similarly showed early recurrence
and a high incidence of adverse events after Con-
tour Thread placement and therefore do not rec-
ommend this technique.6 If patients would really
understand this, they probably would not pay
such an amount of money for a closed thread-lift
suture lift that lasts for only a few months.
Thus far, only two studies showed promis-
ing results with a high satisfaction and overall
improvement rate.3,7 Eremia and Willoughby
showed an improvement of facial laxity up to 16
months after the procedure, with the most favorable
effect seen in the tear trough/malar fat pads and
nasolabial folds.2 However, it should be noted that
this research group received a grant from Angio-
tech, the company that manufactures the Contour
Threads. Also, de Benito et al. showed that thread-
lifting procedures provide stable results with a high
level of satisfaction among patients and surgeons.7
However, we have to also realize that de Benito et
al. received consulting fees from the Silhouette Lift
company for travel and hotel expenses associated
with providing lecture and surgery workshops for
the company.
Atiyeh et al. assessed in a review article not only
evidence-based efficacy but also the general views
expressed in the literature arising from empirical
observation and opinion.11 They conclude that
a surgical approach to redistribute the different
anatomical layers of the face by standard open or
endoscopic face lifts cannot be replaced by simply
suspending ptotic tissue with threads like a mari-
onette. In our review, we did not include articles
about nonbarbed sutures, as one could expect an
even less long-lasting effect with these sutures.
The overall reported rate of serious complica-
tions with thread-lift suture is low. There is, how-
ever, the potential for detrimental complication
of nonreversible scarring after an infection with
threads. Possible long-term damage to the deli-
cate superficial musculoaponeurotic system layer
caused by repetitive scarring must also be consid-
ered, as our first objective is to not do any harm
to precious tissues. Cosmetic doctors using these
techniques are mainly nonsurgeons who have not
been “brought-up” with the principles of sterile
techniques, and learn these procedures often in
1-day industry-sponsored courses.
Despite the lack of evidence for long-lasting
results of closed thread-lift suture lift, its use is
currently still very popular, probably driven by
industry and money-driven cosmetic physicians
promising face-lift results without surgery, a fairy
tale story many potential clients for facial rejuve-
nation wish to believe. Also, because these clients
have already been successfully treated in the past
by their cosmetic doctor with botulinum toxin
type A and fillers, many of them also believe in the
next step offered by them: the nonsurgical face
lift using a closed thread-lift suture lift.12
However, there may be significant advan-
tages when thread-lift sutures are combined with
an open procedure.13,14 For example, the multi-
anchor thread-lift suspension sutures distribute
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 141, Number 3 • Review of Thread-Lift Sutures
347e
tension more evenly among the lifted tissues.15
The microimbrication of a dissected layer, like the
superficial musculoaponeurotic system, is subse-
quently locked by the overlying skin/dermal layer,
thereby locking the “lift effect.” A variant of the
thread-lift suture, the V-lock suture, is nowadays
routinely used in closing wounds without knitting.
As such, thread-lift sutures really can have a defi-
nite role in the future.
CONCLUSIONS
Based on clinical experience and the review
of Villa et al. 11 years ago, the use of thread-lift
sutures to perform a closed minimally invasive
“face-lift procedure” was considered to be a very
promising technique. However, our review clearly
demonstrates that, in the past decade, little or
no evidence has been added to the literature to
support this statement. All included literature in
this review except one study demonstrated very
limited durability of the lifting effect. Only two
studies, sponsored by the companies that manu-
facture the thread-lift sutures (Contour Threads
and Silhouette sutures), reported positive results.
A limited direct lift effect with short longevity is
our main conclusion of this systematic review of
the closed thread-lift suture lift in the face. Only
the use of thread-lift sutures in combination with
an open procedure seems to be promising.
Berend van der Lei, M.D., Ph.D.
University Medical Center Groningen
P.O. Box 30.001
9700 RB Groningen, The Netherlands
b.van.der.lei@umcg.nl
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15. Tonnard P, Verpaele A. The MACS-lift short scar rhytidec-
tomy. Aesthet Surg J. 2007;27:188–198.
... 5,16 Early technologies mainly used nonabsorbable sutures, such as Aptos Thread, Woffles thread, Isse's Endo Progressive Facelift suture, Contour threads, and Silhouette suture, which can compete in efficiency with face lifting, but remain in the skin forever, often causing complications, such as expulsion. 11,17,18 Soluble threads made from polydioxanone, polygluconate, polycaprolactone, or poly-L-lactic acid, as well as their copolymers, give fewer complications, especially in the long term. They are now more popular, although their effectiveness is still estimated ambiguously. ...
... Many authors mention that large-scale blind clinical trials on the long-term consequences of minimally invasive facial lifting procedures are missing, while a 6-to 12-month follow-up or even less is not enough to assess the duration of thread lift results, as the procedure has both short-and long-term consequences. 3,18,24 A few papers present the results of patients' follow-up only for the first 4 to 6 months after thread lift. 7,20 Few researchers provide statistical data on the results of the 2 or more years of follow-up. ...
... 12,20 These studies showed that the data obtained by measurements correlated with the results of the visual methods; therefore, subjective data are considered reliable, provided the assessment methods meet the requirements: to be blinded, performed by several certified facial plastic surgeons on a large number of patients, and with long follow-up periods. 17,18 In our research we complied with all these requirements. ...
Article
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Background In recent years thread lift has become widespread; however, existing methods need to improve their long-term outcome, which requires considering topographic anatomy of face and neck, especially the ligamentous apparatus. This study aims to assess the effectiveness and safety of an innovative method of one-time three-step thread facelift, which provides an additional support to the ligamentous structures of the upper, middle, and lower thirds of the face and neck. Methods The study included 357 patients aged 32 to 67 years with various morphotypes of aging. The original method of thread lift was applied, and its effectiveness was followed up for to 2 years. The Wrinkle Severity Rating Score (WSRS) and Global Aesthetic Improvement Scale (GAIS) scores were used for assessment by investigators, independent observers, and patients. Statistical significance was determined using paired t-test and chi-square test. Results The mean WSRS score was 3.88 ± 0.88 before the thread lift, 1.93 ± 0.81 one month after the procedure, and 2.36 ± 0.85 after 2 years of follow-up. The mean GAIS was 4.80 ± 0.04 one month after thread lift, and 4.01 ± 0.04 after 2 years, while in the patients' assessment Global Satisfaction Scale was 4.86 ± 0.02 and 4.10 ± 0.02, respectively. There were no clinically significant complications throughout the observation period. Conclusion The new method of one-time three-step thread fixation of the soft tissues of the face and neck demonstrated a high degree of satisfaction by both experts and patients after 2 years of follow-up. It showed high efficacy and safety, including in the group of patients with pronounced age-related changes of the skin of face and neck.
... The PDO threads induce tissue changes and are generally free from these mechanical variables. [24] In our cases, those with mild to moderate wrinkling and textural changes reported higher degree of satisfaction (VAS > 2+), however those with severe wrinkling, and "under eye bags" reported lower satisfaction and were also observed to have responded poorly to the procedure [ Figures 5 and 6]. The complex multifactorial etiology of under eye puffiness emphasizes that no one single procedure may benefit these cases and each individual must be assessed and treated accordingly. ...
Article
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The periorbital region, a major impressionable area holds a special place in aging of the face. It reflects chronological aging which are reflected not only as structural changes but also emotive expressions of sadness and tiredness. Dermal threads have been used in combination with other aesthetic procedures, however their use as monotherapy especially in periorbital region needs evaluation. Aim: To evaluate the improvement in wrinkling and skin texture in the infero-lateral periorbital region with monofilament dermal threads. Settings and Design: A prospective observational study in a tertiary hospital was conducted between January 2019 and February 2020 after institutional ethical clearance and patient consent. Materials and Methods: 25 adults between 40 and 65 years of age reporting for infero-lateral periorbital rejuvenation and opting for dermal threads, with no history of aesthetic treatment in this region for the past three months were included after their informed consent. 10 monofilament dermal threads (5 each in lateral and infraorbital) in either periorbital region were inserted. Cases were assessed with Lemperle’s wrinkle scale and visual analog scale (VAS) and photographic record maintained before procedure and after 16 weeks of procedure. Change in wrinkle grade was analysed using paired t-test and VAS was used to assess patient’s perception of the result. Results: 25 cases were included in the study, 21 completed the follow-up and 4 were lost to follow up. The mean preprocedure wrinkle score was 2.29 and postprocedure mean scores were 1. This finding was statistically significant. 16 cases were satisfied with their textural improvement (VAS >+2) while 4 reported mild improvement (VAS 2+) and 1 reported no improvement. Side effects observed were bruising in two cases and thread displacement in one case within 24 hours. Conclusions: Polydioxanone monothreads offer an alternative aesthetic procedure for periorbital rejuvenation.
... 49,50 Theoretically, even if you do obtain a significant lifting effect on the mouth corner, there is a chance that this effect may disappear as a result of the cheesewire effect after repetitive motion of the mouth and face. 51 However, because this review included only 1 study that used a thread lifting procedure with a follow-up period of 6 to 16 months, a firm conclusion about the long-term effect cannot be made. It would be interesting if there were more studies investigating the effect on the position of the corners of the mouth after a rhytidectomy or a rhytidectomy combined with a direct surgical mouth corner lift. ...
Article
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Abstract Background Mouth corners are an essential part of the centro-facial area for perception of attractiveness and emotions. Downturned mouth corners are a result of aging or have a congenital origin. Different mouth corner lifting techniques are described in the literature. Objectives This review was performed to systematically assess and compare invasive and non-invasive mouth corner lifting techniques and their effectiveness, patient satisfaction and adverse effects. Methods MEDLINE (via PubMed), EMBASE and The Cochrane Central Register of controlled trials databases were searched for clinical and observational studies published in peer-reviewed academic journals with abstracts available (searched from May 18, 2019, to December 18, 2021). Outcomes of interest were aesthetic mouth corner lifting techniques, the degree of lift as well as the longevity of the lifting effect, patient satisfaction and adverse effects. Techniques were subdivided in invasive techniques and non-invasive techniques. Results Eleven out of 968 studies were included in the qualitative analysis. In general, surgical techniques seem to have a better mouth corner lifting effect in comparison to non-surgical techniques; however, objective evidence is weak, and surgery inevitably results in a scar. Reported patient satisfaction was good for both surgical and non-surgical techniques and no severe complications have been described. Conclusions Surgical techniques seem to have a better lifting effect on mouth corners than non-surgical techniques. Nevertheless, objective evidence is weak, and a scar is inevitable.
Article
The diagnosis and treatment of pelvic organ prolapse (POP) remain a relevant and scientifically challenging topic. The number of cases of genital prolapse increases each year, one in ten women need at least one surgical procedure and one in four women in midlife have asymptomatic prolapse. Using mesh implants to correct POP presents unsatisfactory clinical outcomes, requiring hospital readmission and further surgery. We hypothesize using an alternative surgical intervention technique, applying injectable biodegradable cog threads, currently used for face lifting procedures, to reinforce and correct vaginal wall defects. The threads used in this investigation are commercially available 360° 4D barb threads (PCL-19G-100), made of polycaprolactone (PCL), supplied in sterile packs (Yastrid, Shanghai, China). Eleven sows’ vaginal walls were used to analyze the immediate reinforcement effect of the threads. Uniaxial tensile testing and scanning electron microscopy (SEM) was performed for the initial characterization of the threads. Threads were inserted into the vaginal wall (control n = 5, cog n = 5) and were characterized by ball burst testing; a pull-out test was performed (n = 6). With SEM images, dimensions, such as thread diameter (≈630 µm), cut angle (≈135°), cut depth (≈200 µm) and cog distance (≈1600 µm) were measured. The mechanical behavior during uniaxial tensile testing was nonlinear. Threads could sustain 17–18 N at 18–22% of deformation. During the ball burst test, vaginal tissue reinforced with threads could support 68 N more load than normal tissue (p < 0.05), indicating its strengthening effect. Comfort and stress zones were significantly stiffer in the tissues reinforced with threads (p < 0.05; p < 0.05). Both groups showed identical deformation (elongation); no significant differences in the comfort zone length were observed, showing that threads do not affect tissue compliance. The pull-out test showed that the threads could sustain 3.827 ± 0.1891 N force when the first cog slip occurs, at 11.93 ± 0.8291 mm. This preliminary research on using PCL cog threads for POP treatment showed promising results in increased vaginal wall resistance to pressure load and, at the same time, not affecting its compliance. Nevertheless, to obtain long term host response in vivo, further investigation will be carried out.
Article
Background: Non-surgical, minimally invasive techniques are an effective way to bring a facelift with long lasting results; and minimal downtime and side effects. Due to an increased awareness and growing social acceptability, a large number of patients have been seeking these treatments to maintain a youthful appearance. Objective: To assess the efficacy of combined use of PDO threads and hyaluronic acid fillers for non-surgical facelift in a male patient. Method: A 39-year-old male patient underwent a non-surgical facelift using a combination of PDO threads and hyaluronic acid dermal fillers. Treatment was done in two sessions at an interval of one week using 4 pair mint PDO cog threads in the first session followed by injection of 5ml of hyaluronic acid dermal filler (4 ml JuvedermVoluma and 1 ml Juvederm Ultra Plus). Results: Combined use of PDO threads and dermal fillers is an effective technique for face lift and to correct sagging. Significant improvement is seen within a week of procedure which ensures high degree of patient satisfaction. Conclusion: Facial rejuvenation and lifting using PDO cog threads and hyaluronic acid dermal fillers are effective in providing immediate, long lasting results with minimal downtime.
Article
Background: Aging is an inevitable process. Eyebrows, cheeks, mandible, and neck are the areas that are the most vulnerable to the aging process. The most commonly thread lifted areas of the face are the jawline, midface, eyebrows, and the neck. Patients and method: In this retrospective study, patients who were treated with thread-lifting between January 2018 and April 2020 were evaluated and the following were noted: the age and gender of the patient; the type of thread used; number of threads used; treatment area; patient satisfaction; and complications. The effects of age, type of thread used, number of threads used, and treatment area on patient satisfaction were analyzed statistically. Results: The relationship between age and patient satisfaction is statistically insignificant, p = 0.697. The relationship between patient satisfaction and the type of the thread used was insignificant, p = 0.533. There is no relationship between the number of threads used and patient satisfaction, p = 0.783. There is no difference in patient satisfaction between treatment areas, p = 0.930. The most commonly observed complications were edema, pain, and ecchymosis. Conclusion: We report that the patient satisfaction in thread-lifting is independent of the patient's age, treatment area, type of thread used, and the number of threads used. Our study is novel as it is the first study to report that the age of the patient and the thread type do not effect patient satisfaction.
Article
Background Acne scars are one of the most common cosmetic concerns causing psychosocial distress. Objective To evaluate the efficacy of subcision versus its combination with either cross-linked hyaluronic acid (HA) or poly-l-lactic acid (PLLA) threads in the treatment of atrophic post-acne scars. Methods Forty patients of both genders with atrophic acne scars were subjected to subcision 1 month apart for 3 sessions. After the last session of subcision, the patients were reclassified randomly into 2 equal groups each received either HA or threads in one side of the face leaving the other side that underwent subcision before as a control. Clinical assessment was carried out by the physicians and patients. Photographs and skin biopsies were obtained. Follow-up was 6 months. Results A significant clinical improvement was achieved in 67.3% of patients after subcision alone compared to 94.1%, 82.4% of subcision combined with HA or threads, respectively. Patients’ satisfaction was higher in the combined groups compared to subcision alone (p < 0.0001). Side effects were tolerable and transient. Conclusion Subcision combined with HA or threads could offer a higher significant clinical improvement of acne scars than subcision alone.
Article
Introduction One of the most frequently performed anti-aging surgical procedures is thread facelift. Since the 2010s, thread lifts using absorbable polydioxanone (PDO) thread were developed and have become increasingly popular. This research aims to identify the changes in and the mechanisms of absorbable thread-lifting components, namely, PDO (polydioxanone) and PCL (polycaprolactone), with varied absorption periods in the body. Methods Four different types of threads, namely, single-stranded thread, 4-stranded thread, 12-stranded thread, and barbed Cog thread, were used for each component. Histological changes in the thread and neighboring tissue of rat model were investigated for 2-week interval, and PCR was conducted for genes related to fibroblast proliferation including type 1α1 collagen, type 3α1 collagen, transforming growth factor beta 1 (TGF-β1). Results An increase in the collagen formation in all types of PDO and PCL groups was observed during the first 12 weeks and decreased afterward. Collagen formation decreased later in the PCL thread group significantly than the POD group. PCL thread remained logner in the tissue for over a year regarding POD requiring around 24 weeks of absorption–degradation. A larger surface area between the thread and the tissue induces a greater response in the tissue, resulting in an increase in inflammatory cells, myofibroblasts, and fibroblasts. Results showed a similar pattern of increase in type 1α1 collagen and TGF-β in the PDO thread group. This suggests that TGF-β signal transduction leads to fibroblast proliferation that stimulates collagen formation and tissue re-formation. In contrast, only type 3α1 collagen increased in the PCL thread group. Conclusion More collagen formation and tissue responses are induced by PCL thread, remaining longer in the tissue than PDO, leading to more tissue tightening effects that is one of the most important points of face lifting. Morphological comparison of threads shows that not only an increase in surface area between thread and tissue but also multi-strand increase tissue response, which in turn increases tissue maintenance effects.
Article
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BACKGROUND: Facial aging leads to loss of structural integrity. OBJECTIVE: To develop a means of supporting ptotic facial tissue without facelifting. METHODS: Polypropyline sutures were modified by designing many dents along their lengths. These “APTOS” threads hold tissue firmly because of the sharp edges to the dents. These threads were used to lift facial tissue in 186 patients. RESULTS: APTOS threads proved successful in lifting various ptotic areas of the face, improving facial contour. Improvement persisted in most patients with follow-up of two months to 30 months. In four patient (2.5%) the thread failed. CONCLUSION: Lifting facial tissues using APTOS threads is simple, constructive, and time-saving. It avoids scars and the need for implants.
Article
This article outlines a new rhytidectomy technique, developed by the author, that utilizes bidirectional self-retaining (barbed) sutures for superficial musculoaponeurotic system (SMAS) plication and, in some instances, skin closures. Short-scar and traditional versions of the procedure are presented, and the history of purse-string SMAS plication and the advantages for using self-retaining sutures in this application are discussed. © 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.
Article
Thread lifting is a minimally invasive technique for facial rejuvenation. Various devices for thread lifting using polydioxanone (PDO) are popular in aesthetic clinics in Korea, but there have been a few studies regarding its use. To describe PDO thread and techniques adopted to counteract the descent and laxity of the face. A retrospective chart review was conducted over a 24-month period. A total of 31 thread lifting procedures were performed. On each side, 5 bidirectional cog threads were used in the procedure for the flabby skin of the nasolabial folds. And, the procedure was performed on the marionette line using 2 twin threads. In most patients (87%), the results obtained were considered satisfactory. Consensus ratings by 2 physicians found that objective outcomes were divided among "excellent," "good," "fair," and "poor." Texture wise, the outcome ratings were 13 as excellent and 9 as good. Lifting wise, ratings were 11 as excellent and 6 as good. The incidence of complications was low and not serious. Facial rejuvenation using PDO thread is a safe and effective procedure associated with only minor complications when performed on patients with modest face sagging, fine wrinkles, and marked facial pores.
Article
There is a growing trend nowadays for patients to seek the least invasive treatments possible with less risk of complications and downtime to correct rhytides and ptosis characteristic of aging. Nonsurgical face and neck rejuvenation has been attempted with various types of interventions. Suture suspension of the face, although not a new idea, has gained prominence with the advent of the so called “lunch-time” face-lift. Although some have embraced this technique, many more express doubts about its safety and efficacy limiting its widespread adoption. The present review aims to evaluate several clinical parameters pertaining to thread suspensions such as longevity of results of various types of polypropylene barbed sutures, their clinical efficacy and safety, and the risk of serious adverse events associated with such sutures. Early results of barbed suture suspension remain inconclusive. Adverse events do occur though mostly minor, self-limited, and of short duration. Less clear are the data on the extent of the peak correction and the longevity of effect, and the long-term effects of the sutures themselves. The popularity of barbed suture lifting has waned for the time being. Certainly, it should not be presented as an alternative to a face-lift.
Article
Currently, the face can be reshaped with minimally invasive procedures. This report describes how the midface can be suspended by increasing the projection of the malar area, decreasing the nasolabial fold depth, and improving the jaw definition using 3-0 polypropylene sutures with absorbable cones (Silhouette Sutures). Preoperative skin marks were made to indicate the four points on each side of the face where the sutures would exit through the skin: 1 cm lateral to the middle of the nasolabial fold, at the corner of the mouth, and on the line from the lateral corner of the lips to the angle of the mandible. The sutures were inserted through a 1.5-cm incision positioned in the temporal area. After insertion of the needle, the sutures were fixed to a small polypropylene mesh over the deep temporal fascia. A total of 316 patients were treated between January 2007 and December 2009. The results over a mean follow-up period of 18 months were good, with high patient satisfaction. All the complications experienced by 42 patients (13.3%) were minor and temporary including temporal area pain (7%), visible dermal pinching (3.5%), hematoma (1.3%), asymmetry (0.6%), and suture palpability (0.3%). There were no infections. Face-lifts were performed for 257 women with a mean age of 47 years and 59 men with a mean age of 49.5 years. This procedure can be performed for various age groups to rejuvenate and reshape the middle face. Men whose scars cannot be easily hidden due to baldness are good candidates as well. The technique led to stable results and only minor, temporary complications, with a high level of satisfaction among patients and surgeons. The longevity of the results beyond the mean follow-up period of 18 months needs to be determined.
Article
Barbed suture lifting is a minimally invasive procedure for rejuvenation of the aging face. Few studies have examined its efficacy and associated risks. To evaluate the morbidity associated with this procedure and its long-term effects. A retrospective review of 29 cosmetic patients who underwent thread lifting was conducted. A chart review provided information on patient demographics, surgical technique, and postoperative course. Analysis demonstrated that adverse events occurred in 69% and early recurrence in 45% of the patients in the study group. The incidence remained high upon extraction of independent variables, including technique used, location of thread placement, and number of threads placed. Indications for performing minimally invasive cosmetic surgery include obtaining outcomes comparable with those of an established widely used criterion standard. The goal for new procedures should be to deliver predictable long-term results while providing less morbidity, less downtime, and greater patient satisfaction. The results of this study indicate that the barbed suture lift was unable to accomplish these goals. This study also reflects the importance of a critical review of the ever-expanding options available to aesthetic surgeons.
Article
To evaluate the long-term success of the thread-lift procedure for facial rejuvenation. Thirty-three patients underwent a thread-lift procedure alone or in combination with other facial rejuvenation procedures to the brow, midface, jowl, and neck. Ten patients underwent thread-lifts only, and 23 had thread-lifts with other procedures. Ten additional patients having had non-thread-lift rejuvenation procedures, including lipotransfer, chemical peels, and rhytidectomies, were randomly designated as controls. The mean follow-up period was 21 months (range, 12-31 months). Photodocumentation was obtained at each visit. Long-term aesthetic results were evaluated by 4 independent, blinded, and board-certified facial plastic surgeons. Each result was graded on a scale of 0 to 3, with 0 indicating no change; 1, minimal improvement; 2, moderate improvement; and 3, considerable improvement. The population was divided into 3 groups for comparison. Two-tailed t test (P = .05) was used for statistical analysis of aesthetic outcomes. Although aesthetic improvement was noted in all groups at 1 month, measurable results persisted to the end of the study for all but the group that underwent the thread-lift procedure only. Aesthetic improvement scores of the non-thread-lift control group were better than the group that underwent thread-lift only. Similarly, when the thread-lift was combined with other procedures, scores were better than when thread-lift was used alone. Statistical significance was demonstrated in both of these comparisons (P < .01). The thread-lift provides only limited short-term improvement that may be largely attributed to postprocedural edema and inflammation. Our results objectively demonstrate the poor long-term sustainability of the thread-lift procedure. Given these findings, as well as the measurable risk of adverse events and patient discomfort, we cannot justify further use of this procedure for facial rejuvenation.
Article
The search for less invasive surgical techniques to address the effects of facial aging led to the development of barbed polypropylene sutures for facial suspension. Theoretical advantages of these "threadlifts" included limited scarring, rapid recovery, relative safety, and reduced cost when compared with a standard rhytidectomy. The goal of this study was to evaluate the outcomes of patients undergoing threadlifts to determine the actual complication rates, the durability of results, and the rates of reoperative surgery. A single surgeon's initial 2-year experience with 72 patients undergoing threadlifts was retrospectively reviewed. Preoperative patient demographical and clinical data, operative information, and postoperative outcomes data were compiled and evaluated. A total of 72 thread lifts were performed by 1 surgeon over a 24-month period. Of these patients, 76% underwent threadlift alone, whereas concomitant procedures were performed in 24% of patients. Minor complications were common and usually self-limited. Forty-two percent of patients underwent a secondary procedure after primary threadlift, an average of 8.4 months after the original surgery. Thirty-one percent of patients required revisional surgery for cosmetic reasons an average of 8.7 months after their threadlift. Eleven percent of the patients ultimately required removal of palpable threads. Threadlift is a safe procedure associated with minor complications. Rates of revisional surgery for cosmesis are high after threadlift. Time to revisional surgery for cosmesis is short. Results achieved by threadlift are subtle and short-lived. Threadlift is not a minimally invasive replacement of surgical rhytidectomy. Patients should understand the limitations of this technique and its high rates of revisional surgery.