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

Abstract

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.).

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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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