Commentary on: Effectiveness, Longevity, and Complications of Facelift by Barbed Suture Insertion

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Facial Surgery
DOI: 10.1093/asj/sjy340
www.aestheticsurgeryjournal.com
Facial Surgery
Commentary
Commentary on: Effectiveness, Longevity, and
Complications of Facelift by Barbed Suture
Insertion
WofflesT.L. Wu, MD
Editorial Decision date: December 20, 2018.
The authors of this paper, Bertossi etal,1 are to be con-
gratulated for a timely review of barbed suture facelifts
utilizing dissolvable threads (polydioxanone [PDO]) in 160
patients, with the appropriate conclusion that all initial
improvements of facial lifting or contouring were absent
at 1year.
This reflects what many of us who are actively involved
in threadlifts have believed: that dissolvable threads do not
last and as they dissolve, all benefits are lost, which has
been clearly shown through this study. As the authors and
others have demonstrated, it is indisputable that thread-
lifts, whether dissolvable or permanent, can create a lift-
ing and shaping of the facial soft tissues.2-6 It is only the
duration of the effect or the longevity of the result that is
constantly called into question (Figure 1).
In their retrospective analysis of 160 threadlift patients,
Bertossi et al have carefully documented the type of
threads utilized in their cohort of patients, the method of
insertion, whether there was any intraoperative discomfort
or pain, any postoperative sequelae, and the results, which
were evaluated at 1, 6, and 12months. The quality of the
photographs, which appear standardized for size, lighting,
and head position, are superb and makes it easy to com-
pare the preoperative and postoperative appearances.
Bertossi etal have determined that the average expendi-
ture of their patients for each threadlift was approximately
40% of the surgeon’s fee for a traditional facelift, which
enables us to put into perspective whether the cost justi-
fies the short duration of action.
The authors have also included a useful discussion of
the different kinds of threads currently available and how
they are inserted and deployed. Unfortunately, they were
unable to evaluate the efficacy of the Woffles threads,
because these threads are presently not commercially
available. The Woffles thread is the thread utilized in the
Woffles lift, which is the method that the author of this
commentary has employed for the last 16years.
The statistic in this paper that concerned me most was
the complication rate, which occurred in 55 of 160 patients
(34%) and included superficial displacement of the threads
(11.2%), self-resolving erythema (9.4%), skin dimpling
(6.2%), infection that necessitated suture removal (6.2%),
and facial stiffness that ultimately resolved (2 patients).
I would no longer include erythema, dimpling, or facial
stiffness to be complications, because they occur routinely
in threadlifting and eventually resolve spontaneously.
A more accurate complication rate would therefore be
17.4%, which is still high but was possibly related to tech-
nical issues during the insertion of the threads or sterility.
With time and experience, however, this statistic should
decrease significantly. If it does not, then that particular
type of thread utilized in this study and/or its application
may be problematic.
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Aesthetic Surgery Journal
2019, Vol 39(3) 248–253
applyparastyle "fig//caption/p[1]" parastyle "FigCapt"
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Dr Wu is a plastic surgeon in private practice in Singapore.
Corresponding Author:
Dr Woffles Wu, 1 Orchard Boulevard, Suite 09-02, Camden Medical
Centre, Singapore 294615, Singapore.
E-mail: woffles@woffleswu.com
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Wu 249
Historical Perspective
A review of the history of barbed threads is perhaps
useful at this juncture. Although some of this information
is documented in the literature,7 Iam able to shed light
on the evolution of the threads and their incorporation
into facial cosmetic procedures, having been intimately
involved in the history of threadlift development and
having performed over 1000 threadlifts.
Although barbed sutures were first described by
Alcamo8,9 in 1961 and 1964, Fukuda10 in 1984, Buncke11 in
1999, and Ruff12 in 2001, they were primarily conceptual-
ized and utilized for suturing wounds without having to tie
any knots. No facial cosmetic applications were described
or practiced by these authors at thetime.
The first cosmetic application of barbed threads in the
face was by Marlen Sulamanidze etal,13 who first described
his Aptos Lift sutures in 1999 and published his results in
AB
C
Figure 1. This 75-year-old white man shows severe jowling, deep nasolabial and marionette folds, and poor cervicomental
angle. (A) Preoperative oblique view. (B) One day postoperative with significant correction of aging deformities. Eight lines (4
Woffles threads) were utilized on either side. (C) Three months postoperative showing mild recurrence of the marionette lines,
but the patient is happy with the overall result.
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250 Aesthetic Surgery Journal 39(3)
2000. The next barbed suture for facial suspension and
lifting that was described and clinically utilized was the
Woffles thread utilized in the Woffles lift, which as previ-
ously mentioned is the method that Ihave employed for
the last 16years. The Woffles threads were manufactured
for me by Al Kolster of KMI (Kolster Methods Inc, Corona,
CA). The clinical results were first presented in 2003 and
published in 2004 in this journal.2
All other threads for cosmetic facial use came after
this, including the following: the Isse Threadlift, which
necessitated surgical dissection of the scalp and fixation
of the unidirectional barbed sutures to the temporal fascia;
the Contour threads, which were initially similar to Isse’s
design; the cone sutures (silhouette lift); and many others.
Interestingly, I first contacted Kolster in 2001 and sat
in his workshop to design and develop the 60-cm bidi-
rectional barbed Woffles threads, which were first clini-
cally utilized in 2002. After Sulamanidze and Ipresented
our respective cosmetic cases at a meeting in 2003,14 Isse
approached me with his idea of utilizing similar but uni-
directional threads that would be surgically fixated in the
scalp. I introduced Isse to Kolster, and the Isse threads
were then manufactured and clinically applied.
Subsequently, Kolster was prevented from producing
these threads anymore due to legal restrictions, and the
Contour threads came to prominence. It was at this time
that Isse and Kolster went back to the bench to devise a
new technique, the cone threads, which are now known
as silhouette sutures. Designed and patented by Kolster
and tested and clinically utilized by Isse, these silhouette
sutures became a viable alternative to the barbed threads
available at that time.
The Woffles Lift
As one of the pioneers of barbed suture facelifts, Ihave
been performing my own Woffles threadlifts since 2002
utilizing the patented Woffles thread, which is currently not
commercially available. Made from polypropylene 2.0, the
design of the thread has not changed since Ifirst utilized
it, and I continue to perform these procedures regularly.
The thread is 60cm long, with bidirectional barbs on either
side of a central clear zone that allows the thread to be
folded on itself in the temporal fascia as a self-fixating loop,
thus increasing the pullout strength15 and avoiding any
dissection or knot-tying in the scalp, which aids in rapid
recovery and decreases the incidence of complications.
The original basis of utilizing polypropylene was that it
is a permanent thread that in most patients elicits a cap-
sule formation around it, and this internal “scar” acts as
an exoskeleton, adding to the strength of the thread, its
adhesion to the soft tissues, and ultimately the longevity of
the result. With correct deployment of the threads from the
jowls to the temple, passing from the subcutaneous plane
through the SMAS to the temporal fascia, a meshwork of
“neoligaments” is created to counter the inherent sagging
of facial soft tissues. When the lifting is properly applied,
the effect of the polypropylene can be quite dramatic, cre-
ating a strong, youthful ogee contour of theface.
In the current paper being reviewed, Bertossi etal have
stated that for favorable results, the surgeon must have
expertise in muscle kinetics, soft tissue anatomy, thread
mechanics, and immunologic processes associated with
suture placement. I could not agree more. Threadlifts
look easy to perform, but obtaining stable and consistent
results requires all of the above in addition to surgical skill,
aesthetic judgement, practice, and experience that come
from having performed many suchlifts.
The first premise for success is that the threads must be
inserted and secured properly utilizing a completely sterile
surgical technique. Because of the hype around threadlifts
as a nonsurgical, lifestyle, and lunchtime office procedure,
there are physicians who treat the application of threadlifts
as a minor procedure with only token sterility. As a result,
infections and granulomas can occur. If not properly short-
ened, the ends of the threads can abut against the skin
surface or extrude.
For all patients receiving the Woffles lift, the face and
neck as well as the entire scalp and hair are thoroughly
cleansed with chlorhexidine and povidone iodine before
sterile drapes are applied. The threads are then inserted
utilizing careful aseptic technique and trimmed to avoid
protrusion from the skin. The face is molded in an upward
direction, and, once lifted, the face and neck are dressed
with transparent waterproof dressings. Our current com-
plication rate is below3%.
Immediately postoperation, the face typically looks like
a “Joker” with exaggerated facial ogee curves, lifting of the
cheeks, effacement of the nasolabial and marionette lines,
smoothing of the jawline, and elevation of the buccal fat
pad. There may be some dents, which can be smoothed
out by finger pressure, by lightly tapping on the skin, or
by just leaving them alone, because they will gradually
resolve spontaneously over the next few days. Sometimes,
when Ido not want to disrupt any of the barbs by force-
ful tapping, Imay prefer to add a small amount of Volite
(Juvederm, Allergan) to smooth thedents.
With the benefit of 16 years of lecturing on16-24 and
performing the Woffles lift, Iam in a position to evaluate
the usefulness of these barbed sutures and devise strat-
egies for long-term use of the threads. All patients are
informed that it is a temporary facelift effect that needs
to be repeated, with more threads being added as resag-
ging occurs (Figure2). Previously placed threads are not
removed. We explain to patients that a threadlift is not
meant to be a one-off procedure but must be repeated.
The patients are given realistic expectations so they are not
disappointed when sagging recurs.
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Wu 251
In our experience, the longevity has been anywhere from
1 to 9years (Figure 2), depending on the age and health of
the patient, the degree of skin laxity, the thickness of the
skin, and the adequacy of facial volume. Younger patients
with sufficient facial volume and thick skin fare the best,
with results lasting on average 3 to 4years, whereas older
patients with poor elasticity of skin, volume depletion, and
severe sagging may benefit for only a year ortwo.
Certainly, the results are not and cannot be permanent
in any way. Aging is an ongoing process, and the facial
soft tissues will age relative to the threads with consequent
sagging, albeit at a slowerrate.
In closing their article, Bertossi etal state that “barbed
PDO sutures might best be applied in combination with
open facelift procedures.” Idisagree. Patients should be cat-
egorized according to their preferences. They are either sur-
gical or nonsurgical patients. If the latter, then they must be
prepared for the results and short longevity that come with
the many different kinds of dissolvable threads that are
being offered. If the former, there is no point placing dis-
solvable PDO threads in conjunction with an open facelift;
it is better to just perform a full and proper facelift.
In my opinion, dissolvable PDO threads have limited
usefulness. One of the reasons they exist is because thread
AB
CD
Figure 2. This 45-year-old female patient wished to improve early jowls and cheek descent with the creation of more youthful
contours of the face. She had already decided that she did not wish to undergo traditional surgery and yet still wanted to look
youthful and presentable. She preferred a complete nonsurgical approach to her aging. (A) Preoperative oblique view. (B)
Immediate postoperative view after the first Woffles lift procedure. Eight lines (4 Woffles threads) were inserted on either side
of the face. Note the accentuated ogee curve and the restitution of youthful contours with elevated cheekbones, increased
malar volume, effacement of nasolabial and marionette lines, and a better jawline. (C) Four days postoperatively, the patient’s
face looks more normal and the effect of the lift is less dramatic. (D) Four months postoperatively, she has good contours and
shape of her face. (E) One year postoperatively, the correction of the patient’s jowls, midface, and cheeks is still evident. (F)
Nine years postoperative and before the Woffles lift. Despite 9years having elapsed, the patient’s face still looks lifted and
better than her preoperative appearance. (G) Immediately after the second Woffles lift with 8 lines (4 Woffles threads) on
each side. The procedure is essentially repeated without removing any existing threads. (H) The third post operative day after
the second Woffles lift, showing accentuated Ogee curves and correction of aging deformities. (I) One year after the second
Woffles lift and 10years after the first lift, the patient shows a tangible but natural result.
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252 Aesthetic Surgery Journal 39(3)
manufacturers and physicians do not wish to deal with the
legal issues that may arise from improperly placed perma-
nent threads and their complications. With PDO threads, if
there is inadvertent puckering of skin, dimpling, or dent-
ing, the patient can be reassured that the problem will
just dissolve itself away and that their face will return to
normal. However, this is hardly a valid premise on which
to base a cosmetic procedure for someone’sface.
Again, Icommend the authors for a neat, efficient study
and their honest appraisal of a procedure that seems to
have grown in popularity worldwide yet, unfortunately,
has short-term results.
EF
GH
I
Figure 2. Continued
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Wu 253
Disclosures
The author is the inventor (2001) and patent holder
(2004/2012)25 of the bidirectional Woffles barbed thread.
Funding
The author received no financial support for the research,
authorship, and publication of this article.
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