Dr Ruth Harker explores the use of sutures in patients over 60 for a non-surgical neck lift and shares her experience performing this procedure
Thread lifts using polydioxanone (PDO) or poly-L-lactic acid (PLLA) sutures have become mainstream procedures over the last five years in the UK. I believe this is because the risks and downtime are more favourable compared to plastic surgery, although the effect is more subtle. After the age of 40, most Caucasian women’s necks show ageing with thinner, coarsely wrinkled, textured skin. The degree of ageing is commonly related to the amount of UV exposure, Fitzpatrick skin type, and familial tendencies.1 Thread insertion in the neck can provide a pleasing and worthwhile result as patients find it an appealing option to improve their old, sagging necks, while avoiding the risks associated with surgery.
In my experience, the ideal age group is the 40s and 50s. Although a good result is still possible for patients over 60 years old, more caution is needed for patient selection and management. This article discusses the challenges associated with treating patients over 60 and provides some tips for the assessment process. Incorrect patient selection for thread neck lifts will lead to patient dissatisfaction, as well as higher risks of side effects and complications.
As with all treatments, carefully listen to your patient during the consultation to fully understand what it is they really want. Is what they are asking achievable and are they being realistic? In my experience, good candidates for the thread neck lift are those who are fit and well, have robust, good quality skin and are not on any anti-coagulants.2-4 If they have requested a neck lift but you believe it to be unsuitable, explain tactfully why this is so. You should discuss alternatives that might help, such as radiofrequency skin tightening, chemical peels, dermal fillers, botulinum toxin and surgery.
I advise my older patients that I never treat the neck with threads unless the jawline and area under the chin (the dewlap) have been treated first or if they are open to treating that as well. This is because, in older patients, just treating the neck alone can create a peculiar appearance.4 The degree of neck and facial atrophy should be assessed; I believe that if there is no jawline and instead there is a 45 degree drop from the chin to the sternal notch, then a neck thread lift is unlikely to be beneficial. Usually the neck drooping has developed over many years and it is unrealistic to imagine that threads would be able to pull back this weight of flesh. The manufacturers advise the maximum pull-back for any thread is 1cm, and other authors have also reported this.5 If this isn’t enough for the patient, then they either need to approach a plastic surgeon or accept the neck as it is.
It is crucial not to raise older patients’ expectations. When planning thread treatment, I use a soft cosmetic pencil and draw out the path of each thread and demonstrate what can be achieved by pulling back towards the scalp at the nape of the neck by 1cm. Ask if the patient is happy with this, as often 1cm may not be enough to make any appreciable difference with older patients.
Unfortunately, in people over 60, the subcutaneous tissues can be very thin and fragile. In my experience, if the neck skin feels like you are grasping ‘turkey neck skin’, for example, then it is likely that the threads will not hold and may migrate and protrude through the skin, which is unsightly (Figure 1).
Thoroughly explain all possible side effects, adverse events and complications, which are always listed in the manufacturer’s leaflets for the product that you are using. In general, you need to explain that extensive bruising is common in the neck and can look alarming. Cannula methods using PDO anchored threads may be less likely to cause bleeding than the needle methods such as the PLLA threads. The visibility of the thread is a concern; the anchored (barbed) threads are often blue in colour and can be easily visible through thin skin.6 These also have a more rigid consistency, so can feel more uncomfortable. If using PLLA threads, the cones may be visible and palpable through very thin skin.7 I find this is more common if there is not 2cm from the last cone to the exit. Unsightly puckering is more common with older patients as they have more redundant folds of skin, but this should settle with time so patience is needed. Granulomas and infection are also a rare risk.2
Practitioners should always conduct a thorough medical history. For older patients, you must be diligent to consider their age, frailty and medication. Check their medication history carefully; underlying conditions like diabetes or epilepsy may need an adjustment of medications prior to the procedure. If the patient is a diabetic or is prone to soft tissue infections, consider a prophylactic prescription of antibiotics. With age, healing is slower and you should warn the patient of this.2 Anticoagulants are a relative contraindication and it would be wise to decline the case. Even if not taking any anticoagulants, older people often have more ineffective clotting systems and if you find that, on examination, they have spontaneous bruises then they are likely to bruise badly following thread placement. Allergy history, such as asthma, hay fever, contact allergies, drug allergies (particularly local anaesthetic) and suture allergies are also contraindications.4
As well as this, if the patient has experienced recent weight loss, I would recommend postponing the procedure until the patient is at a static weight. Request that they try not to lose any weight before the procedure or for 18 months following; weight is commonly lost off the face and neck after individuals are middle aged.2
An evaluation for body dysmorphic disorder should be made and if you gauge that they seem neurotic or highly anxious it is advisable to use the BDD questionnaire.8 As well as this, check for potential needle/blood phobia and assess the patient’s level of anxiety/ability to relax and lay still for up to one hour. The older person is more likely to have musculo-skeletal aches and pains, meaning they may not be able to do this. Additionally, I recommend assessing their pain threshold generally – will they cope with the procedure? A useful question to ask is ‘how do you cope with local anaesthetic at the dentist?’
Explain that there are several small boluses compared to one large one at the dentist. From cardiology training, practitioners should remember that a raised venous jugular pressure, palpable carotid atherosclerosis, prominent carotid pulsation, canon waves or a carotid bruit all signify various cardiac pathologies.2 If any of these are found, I advise declining the case and refer the patient back to their GP. If there is any history of heart disease or arrhythmia, then you must ask yourself if it’s medically appropriate to perform the procedure as the risk of heart attack or stroke is there.
Although this is a minimally-invasive procedure, one should not be complacent and there is a significant risk the older and frailer patient is. Remember this is not an essential treatment and the physician’s rule is ‘first do no harm’. When assessing patients, you should also examine the quality of connective tissue – is the skin like tissue paper? If so you will not get a good result. The thickness of connective tissue should also be considered. My rule is if you grasp skin over the neck, over the hyoid cartilage thumb and forefinger (or callipers), they should be approximately 1cm apart. If your thumb and forefinger are touching, then this is a case to decline because the connective tissue will be too thin to support the sutures and they may be palpable/visible or migrate and a disastrous outcome may result.9
Practitioners should revise the treatment outcomes again and explain what you are expecting to achieve; draw the path of threads to demonstrate this to the patient. A consent form must be signed, only if both patient and practitioner are happy that every aspect has been covered. In addition, check if the patient has eaten or drunk fluids recently and offer water and/or a glucose tablet if they are feeling hypoglycaemic. Do not proceed until you are sure they are feeling well. If the patient has any allergies or a swelling tendency, antihistamines may help on the day of procedure.14 Lastly, make the patient comfortable, with their neck supported with a comfortable pillow. Remember the patient may have to stay in this position for a prolonged time, which can be difficult for older patients. I find that it is best for the patient to be sitting as upright as they can manage comfortably; when the patient is supine it is easy to get the direction of the threads incorrect. The practitioner needs to see the neck at its worst.
The risk of infection is greater in the older person.2 A sterile technique is essential to prevent infection and a nursing assistant is necessary as one doesn’t want to desterilise the sterile field. Also, the assistant must wear sterile gloves and press on any bleeding point. I advise to keep local anaesthetic to a minimum as it may cause bruising in the neck, particularly under the chin, and also disguise the anatomy you are trying to correct.2 It goes without saying that you must follow the exact procedure that you have been taught on the courses you have attended to learn the particular thread system you are using. Note that only practitioners specially trained and certified are able to obtain Silhouette Soft threads from the manufacturer.
Silhouette Soft is a needle system, whereas PDO threads are a cannula system, and the instructions for use are completely different; the number used and injection technique varies considerably. Generally speaking, in my experience, the practitioner must be gentle when inserting the sutures. Ask the patient to lift their chin up and stretch the skin, which helps keep in the superficial plane and enter at 45 degrees.
Unsightly puckering is more common with older patients as they have more redundant folds of skin, but this should settle with time so patience is needed
Then, when you feel the ‘give’ of passing through the dermis, you must traverse the needle/cannula horizontally superficially, pinching the skin ahead of the needle/cannula, which should be approximately 4mm in depth. Always be absolutely sure that you know where the tip of the needle/cannula is, and keep checking where it is and where it is likely to come out and ensure this is the desired position. Check that the needle/cannula is not in the platysma muscle by palpation and not in the supra-tracheal tissues by asking the patient to swallow before pulling the needle.
Following the procedure, I recommend ice packs, paracetamol or low dose codeine to ease the pain. I advise that the patient sleeps on their back for three to five days, using extra pillows. They should avoid saunas, steam rooms, UV exposure, dental treatments and sports. They should avoid any other activity that strains the neck up or forward for three weeks. Even pilates and yoga, which elderly women often do, may be painful and strain the newly inserted threads. Swallowing may be uncomfortable for several days so softer foods may be preferred. Also make sure the patient abides by the necessary pre-procedural and aftercare instructions; for example, avoidance of non-steroidal anti-inflammatory drugs for two weeks before and two weeks after the procedure.16
Good, thorough treatment preparation and patient selection can prevent a lot of problems and a worthwhile neck thread lift can be achieved even in older patients. However, if what the patient desires is not achievable, don’t carry out the treatment and always stress that results cannot be guaranteed, outlining this in the consent form.
Only practitioners who are specially trained and qualified in performing thread lifts should attempt this procedure. It is essential practitioners attend a course for the particular threads they have chosen to specialise in and repeat this course with live models until they are completely confident in their use. For optimal results, I recommend a cadaver anatomy course as it will help you learn how to stay in the right plane. A foundation of experience needs to be built before the practitioner tries this alone in their clinic.
Suh, Dong Hye et al. Outcomes of Polydioxanone Knotless Thread Lifting for Facial Rejuvenation, Dermatologic Surgery: June 2015 - Volume 41 - Issue 6 - p 720–725
Malcolm D. Paul, Barbed Sutures for Aesthetic Facial Plastic Surgery: Indications and Techniques, Clinic in Plastic Surgery, Volume 35, Issue 3, July 2008, Pages 451-461
Rima F. Abraham, et al, Thread-lift for Facial Rejuvenation Assessment of Long-term Results, Arch Facial Plast Surg. 2009;11(3):178-183. doi:10.1001/archfacial.2009.10
D. F. Horne, M. S. Kaminer Reduction of Face and Neck Laxity With Anchored, Barbed Polypropylene Sutures (Contour Threads).Skin Therapy Letter Volume 11 Number 1 February 1, 2006:p336
Allen, D et al., Assessment of the biological safety of Silhouette Soft Suture: biological safety risk assessment,2015,Chorley Consulting: Alderley Edge, UK
Palm, MD., et al., Cosmetic use of poly-l-lactic acid: a retrospective study of 130 patients. Dermatol Surg, 2010 36(2):p161-70
Wei,Z.,et al., In vitro degradation, hemolysis, and cytocompatibility of PEO/PLLA composite coating on biogradable AZ31 alloy. J Biomed Mater Res B Appl Biomater,2015. 103(2):p342-54