The power of dermal fillers can’t be argued with. Offering instant effects and long-lasting results makes them an essential tool for all medical aesthetic practitioners. In patients with excessive facial sagging, however, results don’t always quite go far enough. So what do you do? Referring patients for surgery is of course an option, but for many patients, it will be out of budget and the invasive nature with lengthy downtime isn’t often very appealing.
According to four seasoned professionals, this is where threads come in. Aesthetic practitioners Dr Victoria Manning, Dr Charlotte Woodward, Dr Zunaid Alli and cosmetic dental surgeon Dr Rita Poddar all have significant experience in performing thread lifts and champion their effectiveness.
“Of course, if there’s volume loss then you need filler, but you may also need to address and lift the fat compartments that have descended over time, which can be achieved using threads,” says Dr Poddar.
Dr Manning adds, “Fillers can go so far in patients with mild ptosis and sagging, but if you use them when you need a decent amount of superficial fat lifted, you will end up with a cushioned face that look unnatural.”
Dr Alli agrees, “I will fill and volumise as best I can using dermal fillers, but sometimes I will need something to lift tissue and hold it in place.” He adds that as well as lifting and repositioning tissues, threads can stimulate collagen production, which offers enhanced, long-term results.
Patient selection
So, are thread lifts suitable for everyone? No. The practitioners agree that ensuring you select good candidates for treatment is essential for successful results. “Usually, we have patients aged 40+ come to us who feel their face is sagging. They have jowling, flat cheeks and their infraorbital fat pads have started to herniate. Some patients will have weak forehead muscles, so they have a drooping brow, which then makes the eyelids look heavy,” explains Dr Alli, noting that these people would be ideal candidates. He also treats patients who have lost a significant amount of weight and are now left with sagging skin.
Dr Poddar adds that patients with heavy-looking nasolabial folds and loose skin on the neck are also suitable, highlighting that age isn’t always a factor; she has treated patients in their late 20s and early 30s who have been suitable candidates.
“My ideal patient is someone with mild to moderate sagging and good tissue integrity – there needs to be enough fat there to actually hold the thread,” advises Dr Woodward, pointing out that a thread lift won’t be suitable for those with advanced sagging; these patients will need to be referred for surgery.
Dr Manning continues, “Patient selection for a thread lift is absolutely key. Threads have had a lot of negative press, but it’s basically down to the wrong patients having treatment. For every 10 patients that come to see me, I will probably only put threads in three.”
It’s not one or the other when it comes to selecting an appropriate treatment, Dr Poddar says, suggesting that practitioners should always consider combining a thread lift with other procedures.
Dr Manning agrees, saying, “We always need to be thinking about combination therapies; whether it’s repositioning with threads, muscle modulation with toxin or volume enhancement with filler, as well as introducing energy-based devices to stimulate further collagen and elastin production – the more combinations you can do, the better the outcome, the better the longevity and the happier your patients are going to be.”
As always, Dr Poddar emphasises that it’s better to under-promise and over-deliver. “Make clear that a thread lift isn’t going to give a surgical result. Downplay the effects it could have and you should then have happy patients leaving your clinic,” she explains.
Preparing for treatment
Before a patient can be deemed suitable for a thread lift, Dr Alli says that a very detailed consultation needs to be undertaken, adding that a cooling-off period is essential. He will offer more than one consultation if he thinks it will benefit the patient, and encourages them to take their time before going ahead. “I talk them through the type of thread I’ll be using and the brand, show them before and after photographs and discuss the clinical evidence in layman’s terms. Of course, I also tell them about all the risks so they are completely informed.”
A full medical history is of course part of this, with Dr Woodward saying this should examine if the patient has any autoimmune diseases, which would usually be a contraindication for treatment.1 However, she notes that treatment can sometimes go ahead if there’s no active disease. “I will often do blood tests to ensure there’s nothing untoward going on,” she says.
Additionally, the practitioners advise checking the patient is not on anticoagulants, they’re not pregnant and aren’t predisposed to keloid scarring. The practitioners agree that optimising skin health is extremely valuable pre-thread lift. “If patients are very slim with thin skin, I will often pre-treat them with something like a radiofrequency microneedling device such as Morpheus8 to boost dermal thickening and provide a canvas to work with,” explains Dr Manning. At the other end of the scale, patients with excess fat can be treated with a cryolipolysis device such as CoolSculpting, she says.
Dr Manning will also sometimes prep the skin with Alonzo three months ahead of treatment in order to stimulate tissue and build integrity. “If you haven’t got enough dermis to place the thread in, you’re going to get dimpling and puckering,” she warns.
They all recommend their patients take Arnica tablets before treatment as, anecdotally, patients do tend to bruise less afterwards.2 “We also ask patients to stop taking supplements such as omega3 because they can increase the risk of bruising,” says Dr Woodward.
Dr Poddar notes that patients are also advised to take paracetamol and have a good breakfast on the morning of treatment as the local anaesthetic injections can sting.
As with all aesthetic treatments, the practitioners advocate taking photographs prior to the procedure at different angles, talking them through with the patient, pointing out any existing asymmetry and, to best manage their expectations, outlining what can realistically be achieved. Dr Manning uses a skin laxity scale to indicate to patients the severity of their concern and better suggest an appropriate treatment combination.3 “It’s a really helpful tool as patients can clearly align themselves to the different grades and appreciate your recommended advice,” she says.
The procedure
When a patient arrives for treatment, their hair is tied back and face cleaned. The practitioners agree that the next step – mapping out the insertion and tracking points – is the longest part of the procedure. “It takes about 20 minutes to make sure you have everything right – I also always show my patient the markings to give them an idea of what I’m going to do,” says Dr Manning.
Dr Poddar adds that the whole procedure can take up to an hour and a half. “This shouldn’t be regarded as a lunch-time treatment,” she says, emphasising that patients should be made aware of the seriousness of it.
Then, the practitioners say it’s time for the most painful part. Local anaesthetic injections are given at the entry and exit points, and can also be used in other areas. “The anaesthetic is the nasty bit,” says Dr Manning, explaining, “I tell my patients it’s eight out of 10 horrible, but short-lived. If they’re feeling a bit anxious, I play cheesy music to distract them!”
She highlights that people will ask why she doesn’t use tumescent anaesthetic all the way through the procedure. “The reason for this is that my patient is my GPS,” she says, explaining, “The patient will be pretty comfortable, but if I go too deep or too superficial, then it’s going to be uncomfortable – without anaesthetic, patients can alert me to this so I ensure I am in the correct plane and avoid hitting a vessel.”
Each practitioner uses a different brand of thread, so techniques can vary; Dr Poddar uses Princess PDO, Dr Alli uses Mint PDO and Dr Woodward and Dr Manning uses Silhouette Soft, MINT PDO and Aptos. The practitioners advise that the number of threads used will depend on the type and severity of laxity the patient is experiencing, as well as the kind of threads being used. Dr Alli notes, “Of course, the more threads you put in, the better because you will be able to lift the tissue in many different directions. You may be lifting heavy tissue, so you need enough force to not only lift, but also to keep it there.”
Dr Woodward highlights, “I tend to work bottom up rather than top down in case the patient has any bleeding that could affect my threads below.”
Once the threads have been placed, the practitioners will review and make any necessary adjustments. They are then tightened and engaged into position.
Following treatment
Patients are advised to avoid exercise for up to two weeks post-procedure. Dr Manning says, “Research has suggested that Silhouette Soft threads take up to 10 days to fully integrate into the tissue.” Paracetamol is a suitable painkiller post-treatment, with Dr Alli advising that non-steroidal medication such as Ibuprofen is not recommended as the threads rely on the inflammation process to stimulate collagen and elastin.
Of course, SPF and sticking to an effective skincare routine is always recommended. Dr Alli adds that it’s important to make clear to patients to come to you directly if they have any questions or concerns, saying, “I’d rather patients ask me a question than look at some of the horror stories on Google!”
Usually, the practitioners will arrange to see the patient at a follow-up appointment two weeks later to check how the threads have settled. They will then be reviewed after three months and any additional recommended procedures will be administered.
The threads will remain in place until they dissolve, which depends on their material. While the threads may have dissolved, results can last much longer and some patients can see effects for up to two years, the practitioners say.
Dr Woodward says results generally depend on the patient’s lifestyle. “If someone’s a marathon runner, results aren’t going to last as long as someone sedentary, for example.” On average, she says they will last about 18 months, adding, “If you treat the brow, longevity is usually just shy of a year.”
Potential side effects and complications
The practitioners note that bruising and swelling are usual side effects associated with a thread lift. “It can be really uncomfortable for two to three days, and then it gets easier,” says Dr Manning. They add that entry-point dimpling can also occur, which can be fixed by releasing the tethering slightly.
Things you don’t want to see include asymmetry, granuloma formation, nerve damage and infection. “It can be difficult to get hold of the infection, and sometimes a suture will need to be removed,” notes Dr Manning.
According to Dr Poddar, “You will mitigate risk by having a thorough consultation with your patient,” adding that using a cannula also helps maintain safety.
“Some patients who are quite thin with low body fat may feel the presence of the thread,” says Dr Alli. He notes that as long as it’s not visible, then he is confident it is in the right place. “One of the greatest risks, though, is lack of result,” emphasises Dr Alli, explaining that this generally stems from poor patient selection. “If the degree of collagen and volume loss is so great that threads aren’t going to do much, you’re going to have unhappy patients,” he says.
Considerations
If you’re considering introducing thread lifting to your practice, Dr Woodward advises seeking training with a reputable company. “Don’t go somewhere that teaches you once and then you’re left to get on with it,” she says, noting that mentorship programmes are most beneficial, whereby you will be supervised and can ask for support whenever you need it.
The practitioners also emphasise the importance of sourcing your threads from a reputable company and avoiding discount websites. “I like being part of a company that has my back if I do have any concerns,” says Dr Woodward, while Dr Poddar adds that product traceability is extremely important and a credible company should provide this.
When choosing products, Dr Poddar says not to be swayed by a low price. “It’s a high-quality product that shouldn’t be underpriced,” she says. “When you use quality products, patient satisfaction will lead to referrals and future bookings, so they are worth the money spent.” Dr Alli adds, “It’s essential that you check the clinical efficacy of the product – it must do what it says on the box.”
Dr Alli’s advice is to have dermal filler/toxin injecting experience of at least two years, or a part-time equivalent, before attempting thread lifts. “From doing so, you will gain a good understanding of the topographical anatomy of the face, the functional anatomy and all of the fat compartments that the face and neck have. Your anatomy knowledge has to be at a very good level,” he notes. If anything happens that is beyond your knowledge level, always have referral pathways in place.
