Aesthetics interviews practitioners about their suture preferences for mid-facial lifting and they explain their best tips for successful and safe treatment
Sutures are commonly used by aesthetic medical professionals due to their lifting capacity and rejuvenation effects. Colloquially known to patients and marketed as ‘threads’, different types of sutures can be placed into the skin, depending on the indication, the treatment area, the protocol, and the desired result.
Historically, both non-absorbable and absorbable sutures were, and still are, used in surgery to close and support wounds and tissues within the body.1,2 The use of a barbed suture to lift ptotic facial tissues was first described in the late 1990s, but the popularity of sutures really took off in the aesthetic world after Contour Threads received the first FDA clearance in 2004.3,4,5
The use of sutures for facial rejuvenation has been met by some level of scrutiny in the past, mainly because of safety considerations and low patient satisfaction. Contour Threads, for example, lost FDA clearance in 2007 due to high post-operative complications such as infection and patient complaints.3,4,6 However, practitioners interviewed for this article believe that developments in technologies and protocols, as well as further knowledge in appropriate patient selection, has enabled the results to improve. They believe that the procedures now have higher safety profiles and even better patient satisfaction.
Although threads can be used across the face and body, according to the practitioners interviewed, a treatment of the mid-face to provide a lift is most commonly performed in UK aesthetic clinics, so this will be the focus of this article.
Consultant plastic and aesthetic surgeon Mr Dalvi Humzah explains that he believes sutures are useful for patients that present with facial sagging and laxity, but are not willing to have a major operation like a facelift. He states, “The downtime is less than a surgical approach as it’s less invasive. It’s good for people who don’t want a lot of work done but want to have a good result very quickly.” In comparison to other aesthetic treatments such as dermal fillers, Mr Humzah adds that by using sutures, the practitioner can achieve a lift in the facial structures, which can’t be achieved with a volumising product, as well as some rejuvenation.
Aesthetic nurse prescriber Yvonne Senior adds, “I absolutely love the versatility of threads, their safety profile and the patient’s response to them – patients get that instant wow factor.” She also mentions that she uses threads, in particular those with cogs, because patients see an immediate lift, as well as results that develop over time.
To see if his patients require a ‘lift’ or a more volumising treatment, aesthetic practitioner Dr Ian Strawford will observe the patient both lying down and standing up to see how their fatty facial tissues move. “Most of my patients are presenting with increasing nasolabial folds due to laxity of the mid-face, jowl formation and a loss of jawline contour – putting volume in doesn’t always address this,” he explains, continuing, “It may be that the patient’s fatty tissue has been displaced downwards so when they stand up, gravity has an effect and everything comes down. If we can demonstrate this, then I know it’s not about putting volume in for them. Instead, it’s about repositioning, lifting those tissues and maintaining that position so the tissues stay in that lifted position when they stand up and gravity has an effect.”
Mr Humzah adds that determining patient expectations is essential for patient selection, “I will almost under-lift their skin with my finger to near where I expect the lift to be. If they are happy with that, then you can go ahead. If they want a really tight face, then threads may not be the best solution; they could be the way forward, but they would need to compare the cost of that compared to something a bit more permanent.” He advises that practitioners show photographs of other cases, showcasing the immediate results as well as the improvement achieved with time.
Aesthetic practitioner Dr Morkel Jacques Otto adds that when selecting patients, practitioners must consider the thickness of the patient’s facial structure. “If you have a patient who has very thin skin and no subcutaneous fat, you will insert the sutures almost directly onto muscle – this isn’t usually a good candidate. You need enough tissue and enough subcutaneous fat to get a good aesthetic result. You can still get some lift, but thin-skinned patients tend to pucker a lot, so it doesn’t look very nice,” he explains.
“You need to have really good consultation and assessment skills for these patients,” Senior points out, explaining that because thread lifts can be more expensive and more invasive than other non-surgical aesthetic treatments, practitioners must select their patients carefully and strongly communicate pricing in their consultation. “Patients often come in thinking that they are going to spend a few hundred pounds and get the results of a facelift, so you should communicate that this isn’t the case,” she adds.
Asymmetry is another consideration that must be pointed out in the patient’s consultation, the practitioners interviewed explain. “No one is symmetrical,” Dr Otto states, adding, “So you need to firstly point out any asymmetry. After the treatment, what you find is people pay more attention to their face and think that you may have caused asymmetry with your threads.”
This is one of the reasons why Dr Otto will always take images before, during and after the procedure. “Pictures are the most important thing. I take before pictures, treat one side of the face and then take a picture again – I call these the ‘half-time pictures’. I then take the patient to the mirror to point out the lift. If you don’t do this, patients may not see a big change because they have already forgotten what they used to look like,” Dr Otto says, adding that if there is no ‘half-time lift’ then the practitioner has not got the technique right.
Very importantly, Dr Otto points out, that in his experience, the treatment must cause some degree of swelling. He explains, “If there is no swelling, which is part of the wound healing response, then there are not going to be any cells infiltrating the area and there is not going to be new collagen formation.”9 He therefore recommends that the patient is not on any non-steroidal anti-inflammatories for pain or discomfort and instead recommends paracetamol or ice.
Immediately before the treatment, Senior will always prepare an aseptic field by cleansing and disinfecting the skin. She will also anaesthetise and map out the treatment area using a pen. This includes entry points, end points and the lines in-between these where the threads will follow, as well as any danger zones to avoid. She states, “The patient has to be completely upright for pre-treatment assessment and marking. Once we have marked these considerations out we check that the vectors are what we want in order to achieve the desired outcome. I never treat without pre-treatment marking and that’s a key factor for looking for any asymmetry – allow yourself enough time to not rush this.”
In aiming for a safe and successful mid-face lift, like other procedures, practitioners must consider infection prevention methods. “The first and most important thing to note is that you must work clean to prevent infection,” stresses Dr Otto, explaining that the hair in particular must be considered for the mid-face lift. He frequently sees other practitioners touch patients’ hair while they are inserting sutures, “This is contamination,” he exclaims, adding, “I put down a hair cap and tape the boarders so that no hair can push through underneath. Then I put a second hair cap on top of this.”
Dr Otto adds that as with other aesthetic procedures, anatomy knowledge is important and you should ensure to not damage the facial nerve. “If you insert sutures above the cheek bones you are near one of the temporal branches of the facial nerves and you run the risk of cutting it. You also have a risk of puncturing veins or arteries and you can cause haematoma, so you have to be very careful when inserting the sutures,” he states.
Prior to the treatment, practitioners must also consider how they plan to tighten the threads, Mr Humzah states, saying that some have the tendency to overtighten, which can cause an unideal aesthetic result. “Never overtighten the suture – the problem is that they can all come apart if they are too tight. Less is more; you just want a correction. The scarring tissue tends to creep up the suture and pull everything tighter, so, if you overtighten it you get a worse result than if you don’t overtighten it,” he proclaims.
Currently, there are four common types of sutures available to the aesthetic practitioner in the UK. These include those made of polypropylene,10 polycaprolactone (PCL), polydioxanone (PDO) and poly-L-lactic acid (PLLA).7 The below types are the sutures of choice for the practitioners interviewed, but note that other types and technologies are available.
Dr Otto and Mr Humzah both use PDO regularly in their practice. Although there are several types of PDO sutures,11 Dr Otto recommends those that have barbs for tightening the mid-face. He explains, “To create a tissue lift, you need hooks to anchor them so the thread will need to have cogs or barbs. The sutures I am currently using have been barbed six-dimensionally and these really hook and grip the tissue to maximise the lifting effect.”
Mr Humzah also chooses to use barbed PDO sutures, and will use these over PLLA when the skin is not extremely saggy and when more stimulation is needed to improve skin quality. “I tend to insert more sutures when using PDO compared to PLLA, as I find the lifting capacity isn’t as strong.12 I find the PDOs are very good at stimulating the skin because you use quite a few threads and you can create a network of tissue support,” he explains.
“If you have a patient who has very thin skin and no subcutaneous fat, you will insert the sutures almost directly onto muscle – this isn’t usually a good candidate”
- Dr Morkel Jacques Otto
Dr Otto says that he can achieve a considerable lift with PDO threads. To accomplish this, he will insert a maximum of 10 barbed each side of the face using four entry points with a 19 gauge cannula. His PDO suture of choice is the IntraVita range, a company of which he is the medical director and trainer.
He explains that for a lift, practitioners should learn a specific insertion sequence. Dr Otto explains his technique, “For a lift, my first thread will go just below the corner of the mouth into the marionette line. That will automatically give you a cheek lift without having to put threads into the cheek. Then you can put another two through the pre-jowl sulcus and through the jowl. Those are the three most important sutures.” He will then insert more sutures depending on the individual patient’s lifting needs.
Mr Humzah uses V Soft Lift PDO sutures, and his best advice to practitioners is to ensure they are not inserting the sutures too superficially. “They are designed to go into the hypodermis subcutaneous plane, rather than intradermally. People can put them in too superficially as it’s very easy to start in the right plane and quickly move into the wrong one. By staying in the hypodermis subcutaneous plane, it prevents visibility of the thread and folds in the skin (puckering), which is what you want to avoid,” he says.
Once the sutures are inserted, the practitioners note that they will trigger fibroblasts to produce more collagen and will dissolve in around six months.7
Mr Humzah explains that in his opinion, PLLA threads are a good option if the patient wants a longer-lasting and more dramatic lift of the mid-face. “If somebody has tissue that is sagging quite a lot and they need a really good lift, I would go for the Silhouette Soft PLLA threads. I get a slightly better lift with PLLA sutures than PDO, although as technology develops this might change.”
Dr Strawford adds that this lifting capacity is the reason he chooses Silhouette Soft PLLA sutures for treating a lax mid-face – he is also a key opinion leader and trainer. “These sutures are unique as they have bidirectional cone technology that makes the suture have long-lasting results, if inserted correctly. With these PLLA threads you get a very strong anchorage and a very strong suspension. I find that with other sutures, because they do not have bidirectional cones, the anchorage isn’t as strong,” he explains.
Dr Strawford continues to explain that a needle is used for the mid-face lift and ten sutures are now recommended by the manufacturers, which will also help improve the appearance of the neck.13 “The use of five sutures on each side allows us to spread the load of the forces against the sutures, creating less individual tension on each individual suture and cone. Therefore, I find that they maintain their position for longer,” he explains.
When inserting PLLA sutures, Dr Strawford’s top tip is to ensure you have a correct tightening technique. He explains, “You need to make sure that the lifting part of the suture is well within the tissues that you are trying to lift. You should not pull them from above, and instead you should just try to reposition those tissues and then anchor them in a better position by holding the skin with your hands and moving it up along the thread. In the past we thought we needed to pull them from above to get a lift, but that’s not the case.”
Once inserted, the sutures will stimulate collagen production and the results will develop over the next 12 months, which is around the time that the sutures will dissolve. However, researchers have noted that the benefits can last anywhere from 18-36 months.6,7,12
It should be noted that in the UK, aesthetic nurses are not permitted to use Silhouette Soft PLLA threads.
Mr Humzah says that after the procedure, it’s common for practitioners to place tape or plasters over the entry points. Although he sometimes still does this, he now more commonly uses a spray-on plaster that he has developed called Derma-Seal. “This acts as an impervious barrier. Occasionally, for someone who wants just a bit more reassurance, I use pink micropore on the skin for support. But, when it’s removed you need to make sure that it’s removed in the right direction – you need to pull the tape upwards and not downwards so you don’t pull the skin down and off the thread,” he explains.
Dr Otto advises against immediate exercise to prevent bruising and swelling and to gently re-introduce it after three days. He adds, “Very importantly, patients shouldn’t make a dental appointment for two weeks following the treatment because the mouth opening can be restricted and it can be uncomfortable for them.”
Similarly, Mr Humzah says that he recommends patients eat softer food until the face settles.
"Patients often come in thinking that they are going to spend a few hundred pounds and get the results of a facelift, so you should communicate that this isn’t the case”
- Yvonne Senior, aesthetic nurse prescriber
Practitioners interviewed all note that because sutures do not have the same volumising effect as dermal fillers, they can be used as a combination and each have their own preference of doing so.
“I often use this combination when the patient has both sagging and volume loss. Using the filler and suture combination is quite useful; some of the fillers, such as polycaprolactone and calcium hydroxylapatite, have a good skin stimulating effect. I tend to use the filler first, wait about two months and then put the thread in after,” says Mr Humzah, adding, “The other combination I’ve used is a skin stimulator called PRX-T33, which has been quite useful for patients who need to address skin quality. I find that it stimulates the skin a bit more and gets the threads to have a bit more grip.”
Dr Otto adds that toxin can be used to treat patients with prominent platysmal bands about two weeks before a thread treatment to get a better lift. He states that this muscle sometimes pulls the face downwards, instead of the desired upwards direction, so the toxin helps with this. “If the nasolabial folds are quite deep I will also use fillers. I will inject the toxin first, then the threads. About a month later I will treat using fillers; usually calcium hydroxyapatite. I inject deep, just above the bone and insert the filler underneath the threads,” he explains.
“Never overtighten the suture – the problem is that they can all come apart if they are too tight. Less is more; you just want a correction”
- Mr Dalvi Humzah
Senior states that although the above considerations are essential when treating patients with threads, before practitioners think about incorporating them into clinic they should think not only about the type of threads they will use, but the support they will get from the suppliers. She says, “Quality training and support is key for any practitioner when they are introducing a new modality. Even after performing threads for more than six years I still need updates, technique changes or improvements, and if I had a complication I know that I will get support. This is something that you can’t put a price on.”
Dr Strawford agrees that good-quality training, which is continuously updated, is essential for successful results. He states, “Using sutures is a technique-dependent procedure and that technique involves everything from selecting the right patient to how they are inserted. If you are not getting the results you want, you may need to either look at another type of suture or do some refresher training.”
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