New generation absorbable threads

HISTORY

Lifting the face with threads is not a new treatment, and we can draw comfort from this time-tested technique. More than 20 years ago, gold threads were created to lift the face and there are still practitioners using this technique today. In 1999 the permanent lifting thread Aptos was created from polypropylene (Anti-Ptosis). More recently, the development of dissolvable threads has created a resurgence in interest of this proven technique.

This article will focus solely on the technique and results associated with non-permanent threads.

MODE OF ACTION

In general, anchoring/lifting threads have a mechanism whereby the tissue catches onto the thread and is then lifted as part of the treatment. The mechanism may be barbs, hooks or cones and can be uni-directional or bi-directional. The axis of lift depends on the direction of insertion and the direction of the cones. The thread material can also create new collagen; for example Poly lactic acid (PLLA). As the PLLA dissolves it creates collagen in the same way as Sculptra, another form of PLLA. The fact that a powder available to us for 20 years can be made into a thread is an amazing feat of technology. Thus this type of thread provides both lift and new collagen. Stimulating threads are smooth and monofilament, readily threaded onto a small needle. They are made from PDO (polydiaxanone) used in surgery for 20 years and made by Ethicon. These threads initiate growth factor release through tissue trauma. Fibroblast activation commences new collagen formation, which is remodelled at four weeks. New collagen has a tendency to shrink as it is remodelled. The effect is one of volume and shrinkage due to the sheer number of threads inserted. Stimulating threads should be considered as microfillers and lifters, providing a meshwork of new collagen, with initial tissue support.

ANCHORING THREADS

In my opinion, the newest generation of absorbable anchoring threads have provided us with a magnificent lifting tool. The technique requires a skill but this should be simple to acquire for most manually dextrous cosmetic doctors, and this type of thread is probably the most familiar. PLLA in a thread format is ready placed onto a 25G needle. The thread may measure up to 12cm and contain several cogs/ barbs/ratchets. Insertion is performed under strictly sterile conditions after the face is marked, locating the entry and exit sites of the needle. The entry and exit sites are anaesthetised with lidocaine-adrenaline mix. The needle is inserted at 90 degrees to the skin and then along the subdermal plane 5mm deep. The needle exits at the marked exit point. The needle is cut off and another thread is inserted. Two or more may be used in both sides of the face. Once the threads have been inserted, the thread is pulled against the tissue so that a reassuring ‘click click’ is heard as the tissues pull up on the cogs/ratchets or barbs. The thread is cut close to the skin and the small wounds protected.

STIMULATING THREADS

In my practice I choose to use the V Soft threads, which are made in Korea under a patented process. They are CE marked as a class 3 medical device and distributed in the UK. They are ready threaded and are made from high-quality needle stainless surgical steel, diamond cut for precision entry into the skin. There are two threads that form the basis of a treatment:

• 29G needle mounted with a 30mm PDO thread (6.0)
• 27G needle mounted with a 50mm PDO thread (5.0)

The needles serve to insert the thread into the tissues and are then removed. The threads must be placed strictly in the sub dermal plane. All of the threads dissolve within 200 days, however they induce new collagen by release of growth factors and fibroblast activation. The improvement of the skin and subdermal tissues follows a four-stage process:

Stage 1: Increased coagulation. Inflammatory phase; vasodilatation, fibrinogens enter tissue. Fibrins develop to form protective shell essential for recovery phase.

Stage 2: Degradation phase. Growth factors released, epithelium stimulated, angiogenesis, inflow of fibroblasts and development of myofibroblasts.

Stage 3: Collagen threads form a three-dimensional scaffold at day two-three.

Stage 4: Three weeks later remodelling of new collagen to form stable, flexible structure. This stage may last up to one year.

Thus, it is the sheer number of threads and their positioning that creates the ultimate correction.

USING STIMULATING THREADS

From my experience, I find stimulating threads extremely versatile. They can be used for eyebrow shaping, to achieve a forehead lift, to open the eyes, fill cheek lines and treat extended crow’s feet. Top-ups are possible, and it is a far less invasive technique that anchoring threads. The results are seen immediately and then improve over three months. The procedural requirements are as per filler injections, and the skin can be anaesthetised with topical anaesthetic for an hour.

Applications

Each type of thread can be used alone or in combination. The indications are similar, although best results are achieved when both types are used in one treatment.

Applications and Indications for Anchoring and Stimulating threads

Contraindications to treatment are standard: pregnancy/breastfeeding, cheloid tendency, poor wound healing, extreme age, recent or current infection and current use of roaccutane.

Stimulating threads are not a substitute for anchoring threads but can be used instead, for example when:

• A young person is requesting rejuvenation
  
• There is an absence of sag
  
• A person not wanting anchoring threads
  
• An anchoring thread patient is not fully satisfied
  
• Treating a small area
  

Or as well as because:

Anchoring:

• Provides substantial lift
  

Stimulating:

• Improves skin quality
  
• Perfects lift
  
• Immediate results continue to improve
  
• Allows less anchoring threads to be inserted
  

FACIAL ASSESSMENT

The key is to define the vectors of the face as these will be the insertion sites for the larger, 27G needles, of which about 10 will be used per side. Thereafter, the aim is to create a meshwork of the finer, 29G needles with 6.0 threads.

TREATMENT

It is best to have an assistant. Lay up the trolley with the 27G and the 29G needles, in two piles for each side, left and right.
Cleanse the skin and mark the vectors with the patient sitting up. The patient may be flat or semi-recumbent for treatment. Insert the 27G needles, through skin at 45 degrees. Change direction once through skin, and continue the insertion along the subcutaneous tissue plane to the hilt. Don’t twist or wiggle the needle, or touch the thread. Leave needles in for a few minutes to start the stimulation phase then take them out smoothly. Apply pressure to any bleeding points. Then create the meshwork with the 29G. Insert these at 45-90 degrees to the vectors, across the lines of Langerhans. The 29G are much easier to insert. The number of threads determines the result; depending on the area. For a full face you will use about 70 in total. The treatment should take less than an hour. There will be some bruising and discomfort. The face should be kept clean and dry for 24 hours. The patient can eat, sleep flat, clean their teeth and perform all facial movements, in the knowledge that it might be a bit sore. I like to encourage a diet rich in protein, fruit and vegetables as a reminder of the collagen creation that will follow the procedure. The skin can become dry for a few days. This responds to moisturiser. Sun avoidance is standard.

ANTICIPATED COMPLICATIONS

Bruising: Just about every patient will bruise, especially with the stimulating threads.
Pain: Both procedures can be painful but with adequate anaesthesia it is tolerable.
Invasion threshold: All patients have a limit of tolerance for procedures. The anchoring threads are not acceptable to everybody; stimulating threads less so.
Discomfort afterwards: Anchoring threads tend to be more painful afterwards.
Limitation of activities: Anchoring threads restrict activities for a few days after the procedure.

UNEXPECTED COMPLICATIONS

Infection: It is rare for the skin to become infected after a procedure due to its rich blood supply. However, the procedure for anchoring threads is more invasive and carries a slightly higher risk of infection.
Nerve compression: This is marked in the consent form but to date there has been no complication of this nature associated with nonpermanent threads, to my knowledge.
Asymmetry: Any perceived asymmetry can be remedied at three months with either thread depending on the site and degree. Always take before and after pictures.
Cheloid formation: This is more common in young people. Ask the patient about cheloid tendencies.

SUMMARY

Threads have now become a part of our repertoire. They lift, reposition fat pads, stimulate new collagen and oppose tissue sag. They may be combined with all other treatment modalities (with about four weeks between each treatment) to create a natural look that lasts about 12–18 months.