Dr Jeremy Isaac and Alex Henderson discuss the common complications which can arise from thread lifting procedures
Minimally-invasive thread lift procedures involving barbed suture insertion have become a popular alternative for correcting facial tissue ptosis.1 The increased demand has resulted from improved material technology, an understanding of biomechanics, an appreciation of facial dynamics and the ageing face paradigm.1
Thread lifting technology is a non-surgical facial rejuvenation procedure accomplished through mechanical repositioning of the ptotic soft tissue envelope with collagen biostimulation, resulting in improved skin texture.2 To achieve optimum thread lift results, practitioners must have good underpinning knowledge in muscle kinetics, soft-tissue anatomy, thread mechanics and immunologic processes associated with the procedure.3
Profound ptosis manifested by soft and hard tissue age changes is impossible to reverse with injectables alone.3 Soft tissue dermal fillers are used to revolumise deep and superficial fat compartments. However, once these compartments have descended with the ageing of the bony skeleton, filler augmentation will not fully reposition the ptotic tissue, instead only volumising in the descent position.3
In this article, we will be exploring how polydioxanone (PDO) threads can give overall improvement to patients’ faces, and some of the complications which can occur.
The non-resorbable barbed thread was introduced in 1989 by Russian surgeon Mr Marlen Sulamanidze to lift the ptotic facial tissue.4 Manufactured from polypropylene, the efficacy and safety of the thread allowed for the emergence of variants of the original anti-ptosis suture (APTOS) threads.4
In 2011, the Food and Drug Administration (FDA) in Korea, which is the world-leader for thread innovations, approved mono 6-0 PDO threads.5 In 2014, China approved PDO absorbable threads and included polycaprolactone (PCL). Poly-L-lactic acid (PLA) threads were then approved in 2018.2 Until 2014, Silhouette Soft was the UK’s primary supplier of biodegradable threads, which were composed of polylactic acid monofilament (PLA) with moulded absorbable cones of copolymers: glycolic and lactic acid (PLGA).2
Since 2014, NeoPharmaUK Ltd introduced the first multi-directional barbed (cog) threads suitable for the treatment of mild to moderate tissue ptosis.5 With increased popularity for PDO thread lifting procedures over this period of time, issues began to surface. Training and stock supplies have been of questionable quality with many companies and practitioners importing illegally CE marked products, in combination with ‘overnight’ trainers farming out courses to capitalise on the ‘in demand’ non-surgical alternative to a facelift.5
In 2016, The Association of Polydioxanone Threads (APDOT) was founded to raise standards and accredit practitioners, as well as being a directory to ‘look up’ PDO thread branding and check on its legitimacy. However, this was quickly replaced with the regulatory body the Care Quality Commission (CQC).5
By 2018, the CQC ruled PDO thread lifting as a ‘surgical procedure’ and any healthcare professional performing this treatment would need to meet full requirement for surgical procedures. Now a regulated practice, practitioners in the UK should be aware that they would require CQC registration to offer this treatment.5
Thread classification includes absorbable or non-absorbable, natural or synthetic and multifilament or monofilament.4 Threads can be moulded, cut or smooth, and the barbs are bidirectional or multidirectional. Barbs are a feature of threads which allows simple anchoring into the soft tissue. By gathering the tissue, this allows for lifting and positioning temporarily. Moulded threads have barbs placed onto them, maintaining the integrity of the thread core and tensile strength. Cut threads have the barbs cut into them, affecting the integrity which helps them dissolve quicker. Threads can be used alone or in conjunction with injectables to minimise over-filling.4
Facial areas with significant muscle activity, such as the perioral region, can be challenging for thread lifting procedures. Excessive lifting of the ptotic soft tissues cranially would be opposed to muscle contraction and upset muscular balance.3 Practitioners who lack an understanding of thread techniques will contribute to the failure of the lifting effect, causing ‘cheese wiring’, which describes the process of suture material cutting through soft tissue, reducing longevity. In addition, facial nerve injury is a severe, but rare complication, which can be avoided by the practitioner having a thorough knowledge of facial anatomy.2 Common complications from PDO threads are bruising or haematoma which can be uncomfortable for two to three days but should resolve.
In a meta-analysis of 26 studies and 8,190 patients, the complication rates for APTOS, Contour, Happy Lift, Phoenix, MINT and Xtosis threads included:3
Absorbable threads were associated with a significantly lower risk of paraesthesia (3.1% vs. 11.7%) and thread extrusion (1.6% vs. 7.6%) than non-absorbable threads. Patients older than 50 had a higher risk of dimpling (16% vs. 5.6%) and infection (5.9% vs. 0.7%) than their younger counterparts. In addition, the long-term satisfaction rate decreased significantly compared to immediately after the thread lift (88% vs. 98%).3
Non-absorbable threads in older patients are associated with a higher risk of complications.6 PDO threads are effective in aged skin rejuvenation, soft tissue retraction and support, showing fewer complications.6 In addition, treatment with thicker thread could be more efficacious.6 Thread results may be limited to around 12 months, which can be an advantage as fillers have been observed up to 12 years post-procedure, but it is crucial to manage patients’ expectations regarding longevity.7 In our experience, combining therapy with fillers may prevent the over-filled, unnatural outcome observed with excess fillers. Significant facial rejuvenation can be achieved by using threads, with improvement seen through combination therapy including botulinum toxin, platelet-rich plasma and fillers.8 Additional studies are needed to evaluate the safety and long-term efficacy of combination procedures.9
A recent study confirmed that swelling is the most common complication from thread lifting, which usually spontaneously resolves within two weeks.2 If swelling persists and fails to show signs of improvement, patients should have a face-to-face assessment to rule out further complications such as infection, abscess and misplacement. Swelling may compromise the lift due to unstable anchorage within the oedema tissue. Management of post-operative swelling includes compression and nonsteroidal anti-inflammatory drugs.2
The incidence of dimpling ranges from 1.7% to 34.5% in the literature, which highlights that older patients are at higher risk of dimpling.3 An effect of ageing skin is more sagging, requiring greater tension to lift and achieve aesthetic ideals. The extra tension risks compromise the biomechanics of the anchorage, thus accelerating relapse with facial dynamism. The thickness of subcutaneous fat tissue exhibits selective atrophy in the ageing population, with a potential risk of superficial anchoring at the dermis during thread lifting.2
In Figure 1, each coloured area shows a different percentage of facial dimpling in 190 patients.2
Paraesthesia includes pain, numbness, tension, facial stiffness, hyperalgesia and tenderness, and usually presents itself immediately.11 In a study of 160 patients who received a facelift with barbed threads, 78% reported none or mild pain, with 22% reporting moderate pain immediately post-procedure.1 In the study, four out of five cases were resolved after two months, with all cases showing full recovery by month three to six.1
Paraesthesia may present in different ways depending on which branch of the facial nerve is affected, therefore, insertion depth is important to mitigate these potential side effects.
Superficial placement produces thread visibility and/or palpability. This presents after the inflammatory process has passed within two to four weeks. Massage therapy is beneficial, and with time the resorbable threads will be hydrolysed. In general, this is not uncomfortable, but it can cause distress for the patient if they are aware of the visible thread. Removal of threads is usually carried out with surgical removal, many practitioners are unable to carry out this procedure. However, if the tip of the thread is palpable, it may be possible to extract and trim back the thread under sterile conditions, although the practitioner should be confident with their ability in this practice.12 As discussed above, superficial placement where a thread is not inserted deep enough can lead to thread exposure. This requires surgical removal and is a severe complication occurring within weeks after the procedure. Once the thread is removed, a full recovery can be seen within two to four weeks post-surgery.3 If you encounter a complication which you feel is beyond your sphere of experience, do not hesitate to refer your patient to an experienced colleague.
Infection following threads is a rare complication but is commonly caused by thread removal. Patients over the age of 50 have a significantly higher risk of infection.9 Signs of infection will include redness, tenderness, swelling with possible systemic involvement including pyrexia and feeling unwell. Symptoms may be unilateral or bilateral depending on the conditions in which they are treated. However, it’s recommended that patients are prescribed antibiotics to prophylactically avoid post-operative infection.4,10
Patients suitable for non-surgical thread lifts are those with mild to moderate signs of skin ptosis ageing. A guide of this would be skin laxity of between 1-2cm; below 1cm would benefit from injectables, and above 2.5cm requires surgical intervention.4
Contraindications for thread lifting are patients with a high BMI, unrealistic expectations, excessively loose and crepey skin and those with particularly heavy ptotic soft tissues where surgical facelift is the gold standard.5
Aesthetic procedures using absorbable PDO threads are an alternative method for facial rejuvenation. Different threads and techniques can be used depending on the patient’s needs. The significant advantages of these techniques are low morbidity and downtime. In-depth training, knowledge of different thread techniques and adequate patient selection are crucial to obtaining good cosmetic results. Due to the complex vascularity involved, practitioners must be confident in their knowledge of anatomy before performing the procedure. Although patient satisfaction initially can be satisfactory and the complication rate low, more studies showing long-term results are necessary.
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