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wrinkles due to the “facial scaffolding”not being able to provide as
much support. Thread lifts or suture lifts involve the use of threads or
sutures made from materials used in surgery to close wounds. When
threads are placed under the skin they can tighten and lift loose or
sagging areas in various parts of the face and body to help reduce the
effects of gravity and ageing, or they can be used to rejuvenate the
face.1
There are three main types of threads currently available;
polydioxanone (PDO), polylactic acid (PLA) and polycaprolactone
(PCA). PDO threads have been around the longest and are made of
a synthetic biodegradable polymer that has been used in surgery for
many years. PDO threads are absorbed into the body over 6 months
by hydrolysis and work by triggering broblasts to produce more
collagen in a targeted area. There are three main types of PDO threads
used; mono, cog and screw threads. Mono threads are smooth without
barbs and are anchored to a point on the face or the scalp. They mainly
tighten the skin and provide a small amount of lift.2 Cog threads have
barbs which hook onto the skin to provide support and lift the sagging
tissue. Screw threads have one or two intertwined threads around the
needle and provide good volume restoration to sunken areas of the
skin. The production of collagen around the threads and their barbs
helps to restore volume and improves the skin texture and elasticity
resulting in a natural aesthetics outcome.
After PDO threads, PLA threads were developed. They are made
from a biocompatible polymer derived from lactic acid that has been
used in many applications such as orthopaedic pins and sutures. PLA
threads are resorbable and regenerate collagen over a longer time than
PDO threads. PLA threads use cones to hook to the tissue and increase
the volume of saggy areas therefore helping to restore shape to the
facial area as well as providing a lift.
PCA threads are the newest threads and are bio-absorbable,
monolament suspension threads of synthetic origin (caprolactone).3
They work by regenerating collagen over a longer time than PDO
and PLA threads. They leave behind a collagen structure that provides
support for the skin, tightens the skin and prevents it from sagging.
Due to the brotic reaction caused by the threads, the lifting and
stretching action will continue even after the threads have been
resorbed. The process of thread breakdown produces molecules of
small molecular weight which subsequently induce the production of
collagen and Hyaluronic acid by the skin. The resulting skin is more
moisturized, revitalized and rm with a long lasting result.
Before deciding what type of thread to use we must consider
the treatment indications and what we are trying to achieve; facial
lift or facial rejuvenation.4 If a patient wanted tissue lifting PDO
monolament threads would be unsuitable as they are placed
supercially, are completely smooth and without barbs. While they
produce a regenerative and rming effect that visibly improves skin
quality they do not provide an effective amount of tissue lifting.5
To achieve a powerful lift with improvement in facial tightening
and rejuvenation, barbed threads must be used. The barbs along the
threads act as cogs to clasp the skin creating tension in the thread
which lifts and suspends the facial area. Collagen is formed around
the threads and their barbs resulting in an increased effect.6,7 Consider
now a patient, who requires a facial lift, there are further factors which
ensure efcacy and longevity of the results (barb length, angle, spatial
distribution and direction of barbs or cones, resorption time and the
collagen-stimulating ability of the thread).
The barbs must have a length that enables them to hook onto the
skin tissue and maintain the lift required. If they are too long then they
become too exible and incapable of lifting the facial tissue. On the
other hand, if the barbs are too short they will not be able to hook onto
the facial tissue in the rst instance. Furthermore, we need to consider
how densely the barbs are placed along the thread length. Threads
with a low barb density will not be able to lift the same amount of
tissue as threads with a high barb density and therefore will not result
in the desired facial lift. In addition, low barb density threads will be
less effective at lifting larger volumes of tissue or heavier tissue and
restrict the practitioner to working only with small amounts of soft
tissue. Of course, a thread must have smooth areas that are barb-free
to ensure there is adequate anchoring and to avoid any puckering of
the skin.
The angles of the barbs also have a place in how much hold is
achieved. If the angle is too small then the lift will be weak, conversely,
if the angle is too big the barb may dig into the thread causing it to
break. The manufacturing process for some threads can result in the
barbs actually digging into the thread, reducing its thickness or gauge
in areas. Ideally, the length of the base of the barb should be equal
to the thickness of the thread. The spatial distribution of the barbs
J Dermat Cosmetol. 2017;1(4):86‒88. 86
© 2017 Wong et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which
permits unrestricted use, distribution, and build upon your work non-commercially.
Hanging by a thread: choosing the right thread for
the right patient
Volume 1 Issue 4 - 2017
Vincent Wong, Raq N, Kalyan R, Hsenriksen
A, Funner R
Derma Clinic, London
Correspondence: Vincent Wong, Derma Clinic, London, Tel
0207 299 0380, Email info@drvincentwong.com
Received: May 15, 2017 | Published: December 05, 2017
Journal of Dermatology & Cosmetology
Mini Review Open Access
Keywords: surgery, polydioxanone, polylactic acid, orthopaedic,
polycaprolactone, hyaluronic acid
Abbreviations: PDO, polydioxanone; PLA, polylactic acid;
PCA, polycaprolactone
Mini review
Ageing causes loss of facial fat, especially around the cheeks, the
eye area, the jowls and the neck. Accompanying this is skin ageing
where the elastic bers in the skin become thinner resulting in loss of
facial elasticity? The two processes result in a longer face an
Hanging by a thread: choosing the right thread for the right patient 87
Copyright:
©2017 Wong et al.
Citation: Wong V, Raq N, Kalyan R, et al. Hanging by a thread: choosing the right thread for the right patient. J Dermat Cosmetol. 2017;1(4):86‒88.
DOI: 10.15406/jdc.2017.01.00021
along the thread will also vary and the more contact there is between
the barbs and the facial tissue, the better the hold. Some threads have
barbs at different angles in order to achieve a 3600 lift; some have
cones to maximize tissue contact, while others have all the barbs lined
up in one line only.
Threads can come as either mono-directional or bi-directional. To
achieve effective lifting of facial tissue the bi-directional threads are
preferred as they provide immediate anchoring to the tissue and the
thread cannot move either way due to the two-way direction of the
barbs. Some mono-directional threads are anchored on both ends at
xed points to enhance stability.8 The nal consideration to make is
how long the thread will last in the tissue. PDO threads will stay in the
tissue for around 6 months, PLA threads around 12 months, and PCA
threads will stay in the tissue for 12-15 months. The longer the thread
lasts the more collagen is stimulated and therefore the result is much
better and longer lasting. PDO and PLA threads cause brosis in the
surrounding area and create type 1 collagen. PCA threads stimulate
the production of type 1 and 3 collagen which helps to improve the
condition of the skin giving a youthful appearance.
How do we decide which thread to use for which patient? Ultimately
we have to look at the age of the patient, the treatment area and what
we are trying to achieve. PDO threads are better at repositioning and
revitalizing tissue but not for providing lift so would be suited more to
younger patients. PLA threads provide some lifting, but again would
be suitable for patients who only require a small amount of tissue lift.
PCA threads provide more lift and are more suitable for patients who
require a small to moderate amount of lift. Other factors that have an
effect on the desired results are the technique used to insert the threads
and the positioning of the threads (Figure 1).9
Figure 1 Decision tree to select the right thread for the right patient.
In summary, each thread type has a place and selecting the right
thread for the right patient is vital to achieve the desired outcome as
well as managing the patient’s expectations. Good skin is essential
as response to the treatment relies on the threads to tighten over the
lifted area. Patients with thin skin may have more chances of sutures
showing, rippling effect and bruising.10 Threads lifts are not suitable
for patients with excessively saggy skin. Threads may not be suitable
if the skin is very aged, thick or damaged, but still it is important
to remember that thread lift, especially PCA, represents an option
for those who cannot tolerate surgical lifting or narcosis. Patients
with good soft tissue volume, less facial fat and a small amount of
skin to be lifted will benet the most from thread lifts. For patients
who desire a lifting and/or revitalization effect, thread lifting is a
minimally invasive technique which is well-tolerated. The procedure
is quick and mostly pain free, although the outcome and nal results
are dependent on the qualications discussed above. There will be
patients for whom surgical lifting will be a more suitable option and
most importantly, we must remember that thread lifts are not designed
to replace surgical lifting (Table 1).
Table 1 Summarizing the different threads
Thread
type Rejuvenation Mild
lift
Mild to
moderate
lift
Moderate
lift Longevity
PDO X 6 months
Smooth
PDO X X 6 months
Cog/
Screw
PLA X X 12 months
PCA X X 12-15
months
Acknowledgements
None.
Conict of interest
The author declares no conict of interest.
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Copyright:
©2017 Wong et al.
Citation: Wong V, Raq N, Kalyan R, et al. Hanging by a thread: choosing the right thread for the right patient. J Dermat Cosmetol. 2017;1(4):86‒88.
DOI: 10.15406/jdc.2017.01.00021
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