Dr Victoria Manning and Dr Charlotte Woodward discuss the treatment of a 49-year-old patient using a new thread protocol that uses 10 sutures
Full face and neck rejuvenation is becoming an increasingly requested treatment in our clinic. We find that most patients request natural results and want to steer very clear of the overdone look. The growing demand to improve ageing with less invasive techniques has led to the success of a new generation of so-called ‘puppet’ facelifts, referring to the lift that threads produce. In our experience, the utilisation of suspension sutures typically results in minimal trauma and meets patients’ expectations.1-3 Regardless of the technique used, any lifting or repositioning procedure should consider the fact that the deeper tissues must be repositioned or filled before the skin is tightened.4
For all of these techniques, soft tissue suspension with absorbable sutures is key.5 Recent understanding and appreciation of the vectors and biomechanics of the sutures that should be applied to achieve optimum tissue elevation has improved the outcomes by repositioning ptotic soft tissues into a more anatomical vertical direction.6 In our practice, thread lifting for correcting ptotic tissue has led to a high uptake in our patients due to its lower risk of complications, minimum length of downtime and effectiveness, than compared to surgery.
In this case study, we will be exploring a newly-launched thread lift procedure for face and neck rejuvenation, focusing on patient selection, methodology and achieved results.
Our patient was a 49-year-old, menopausal, slim, female, with a previous history of long standing, debilitating migraines requiring regular interventions with botulinum toxin, triptans and beta blockers. As a result of these factors, she said that she suffers from constant fatigue and feels older than her years. In addition, she presented with marked signs of photoageing due to previous extensive sun exposure.
Her request was for a subtle facial rejuvenation to make her look less tired. In particular, she wanted to address her nasolabial folds, marionette lines – which she felt made her appear sad, and her early jowls. She desired ‘a natural and fresher appearance’. In the initial consultation, we discussed the risks, benefits and treatment alternatives. We explained that there are a few options for repositioning facial volume and that it can be achieved with several types of interventions, including injections with a variety of hyaluronic acid gels or fat.7,8
However, we discussed that although good results can be achieved with fillers, in our experience their use may result in increased facial volume with unnatural contours, and an overfilled appearance, which is not what she wanted. Ablative or non-ablative resurfacing techniques allow for the improvement of the skin surface, but do not adequately lift the underlying ptotic tissues; an important step in achieving a younger appearance.
We discussed the use of threads to address her concerns, which she found appealing because she required a little bit of volumising as well as a ‘lift’, rather than just volumising. We therefore decided that repositioning using sutures was the preferred option.
We chose poly-L-lactic acid (PLLA) sutures over polydioxonone (PDO) threads as in our practice PDO threads tend to be used for the more hypertrophic ptotic tissues. We chose to use Silhouette Soft sutures with the new XLift procedure as we have found that these threads and protocol have high patient satisfaction. In the initial consultation, we discussed the risks, benefits and alternatives to the Silhouette Soft XLift procedure (explained in more detail below).
We discussed the procedure fully with the patient and ascertained that there were no contraindications to treatment, namely autoimmune diseases, hepatitis B and C, HIV infection, pregnancy and breastfeeding, anticoagulation therapy, body dysmorphic disorder, existing infection, history of keloid formation and patients with unrealistic expectations.9
The patient was also educated about potential adverse events. There have been no major complications reported in most studies on the use of sutures;10,11 however, minor and transient complications occur and are mostly practitioner related rather than product. The common side effects remain to be facial asymmetry, erythema, oedema, bruising, entry-point dimpling, puckering, haematoma and discomfort for up to 14 days.10
Thread migration, extrusion, and scar formation at their sites of entry and exit are the late complications described but are rare and again tend to be due to incorrect suture depth placement.
A two-week cooling-off period was then given, respecting the latest guidance from the General Medical Council.12
Photographs were taken before and after the treatment. This was to not only show the patient what has been achieved following the procedure, but also to point out any asymmetry that may have been present initially, as this can be heightened following a thread lift treatment. We then began the Silhouette Soft XLift, which uses PLLA monofilament sutures and bi-directional cones that are made of polylactic-co-glycolic acid.
The bi-directional cones mean that the fixation method has been modified. Previously, practitioners would use an ‘L’ like formation in the jaw, but better results have been achieved using straight lines so the biomechanics work at optimum efficiency. Also, in our experience, exit points in the scalp fascia rather than in the face give much better anchorage. Although several techniques for thread insertion have been used over the years, from my knowledge and experience, most of them involve the interposition of the soft tissues to the cones, with consequent triggering of inflammatory response and production of fibrosis around them. With this new technique, we find that you get improved anchorage in the temporal fascia so the sutures resist suspension traction, retighten the tissue effectively and therefore provide an immediate strong anchorage in the subcutaneous tissue.
As per the protocol, we used five sutures for each side of the face (Figure 1), rather than three as per the previous protocol. In our experience, this results in a more even distribution of the weight of tissue between more cones and a greater lift of the skin tissue than if you only use three. From treating more than 50 patients over the past year, we noticed that other advantages of treating patients with increased numbers of sutures is that there are fewer complications and results show an immediate lift, without any puckering or dimpling.
Additionally, we have found that recovery time using five sutures is much shorter than with other patients who have been treated with fewer sutures, as the increased number of sutures has been able to spread the forces around each individual cone more effectively, putting tissues under less tension. As there is less tension on individual sutures, this patient, along with others we have treated, reported less pain and less discomfort during the procedure.
The technique for suture insertion is relatively straightforward. Tiny bidirectional cones on the sutures were placed into the subcutaneous layer of the skin under local anaesthetic at the entry and exit points. Xylocaine with adrenalin is our anaesthetic of choice, purely for the vasoconstrictive effect.13 Each suture required three injections at the cones; these not only bring about the tension to compress and elevate the sagging facial tissues, but they also prevent the risk of breakage, migration and extrusion.
The effect of the treatment is two phased. An immediate lift in the face and neck and a regenerative action in the ensuing weeks, which brings about a second gradual and natural lift. This is because after insertion, the cones bring about neocollagenesis that continues over time, helping to increase the volume and restore the shape to the face gradually – typically over a period of six weeks to three months.15
The results were instantly visible after the treatment of this patient. Four weeks following the treatment she appeared to have a more defined jawline, reduced nasolabial folds and presented with malar projection (Figure 4). Improvement will continue to occur after two to three months, when induction of new collagen begins.14 This patient’s results are expected to last up to around 18 months, depending on lifestyle and the heaviness of their tissues.
This procedure was well-tolerated and had an excellent safety record after correct implantation. Patient expectations were met and a natural rejuvenated appearance achieved. Optimal results will be apparent at the three-month review following the secondary neocollagenesis action of the sutures.15 In this patient’s case, we feel that she remains slightly volume deficient and will likely require volume replacement into her midface after her three-month review. In our experience, to fully address the signs of ageing, a combination approach is key to reposition the tissues and volumise. For practitioners considering this procedure on their patients, know that it should not be presented as an alternative to a surgical facelift and should only be seen as a temporary procedure that may be maintained until patient ageing requires further interventions. Patients will be disappointed if they expect the thread facelift to show the same outcome as the traditional facelift surgery.16
Disclosure: Dr Victoria Manning is a global trainer and key opinion leader for Silhouette Soft.