Dr Sarah Tonks explains the process of thread lifting, selecting patients, and the risks and complications involved
Age-related changes in the facial skeleton, musculature, connective tissues, fat and skin manifest with universally-recognised patterns. Advancing laxity in the soft tissues leads to a ptotic brow, jowl formation, nasolabial fold prominence and malar flattening. The appearance is further compromised by hyperpigmentated and wrinkled skin.1
A variety of procedures are available to rejuvenate the ageing face. The most commonly used options in the non-surgical aesthetics clinic are botulinum toxin, dermal fillers and chemical peeling.2 Non-surgical procedures have become popular in recent years as they allow for a faster turnaround time and can be performed outside the theatre environment, making them convenient for patients and practitioners alike. According to the review of the regulations of cosmetic interventions by the Department of Health in 2013, the value of UK cosmetic procedures was worth £2.3bn in 2010 and is estimated to rise to £3.6bn in 2015.3
The history of threads
There has been a renewed interest in thread lifting over the past couple of years in the UK, perhaps because both practitioners and patients are looking for alternative ways of rejuvenating the face for those who do not wish to have injectables, or because they wish to utilise suspension threads in order to create lift. Threads have been marketed as an alternative to more invasive procedures such as a facelift due to the long recovery time or cost associated with a surgical facelift. Russian surgeon Mr Marlen Sulamanidze introduced the use of the barbed suture thread to lift ptotic facial tissues in the late 1990s.4
Variations of this original antiptosis suture (APTOS) have been used, which involve placement of cogged threads along a planned trajectory; the threads are then pulled to lift the skin, secured and trimmed at the entry point.5
Thread lifting is viewed with a degree of suspicion amongst some medical aesthetic practitioners. Indeed, the Contour Threadlift system (Surgical Specialities Corp; Reading; Pennsylvania), which was approved by the FDA in 2005, has since lost its FDA approval due to the high incidence of post-operative complications,6
although new cogged suture variations are now available.7
When reviewing the literature regarding threads, it is important to note that although early data showed inconsistent results and early relapse, as new devices were developed and the indications for each technique were refined, the incidence of complications has decreased correspondingly in later studies.8
When performed properly, thread lifting is associated with minor and infrequent complications.
Look at the indication
It is perhaps better to consider thread lifting as a preliminary procedure, which combines well with other non-surgical procedures, rather than a surgical alternative. Threads can also be used to good effect post-surgery on a patient who has had a facelift and would like to lift the skin again, but is not ready for a second surgical procedure. It is important to distinguish initially between threads that are used for skin rejuvenation and threads that are used for lifting ptotic skin. These are both free-floating threads and not anchored to any point. Those for skin rejuvenation are used to give an overall improvement in the texture and tone of the skin and are monofilament threads, which are used in a lattice-work arrangement, inserted into the dermis. Usually around 10-120 threads are inserted at one time depending on the indication. These straight and smooth threads are mounted on a 25G-31G needle, inserted into the skin, where due to the folding of the thread on the needle mount, it becomes a ‘V’ shape and remains in the skin.9
These threads are most usually made of polydioxanone (PDO). If histology is performed, a foreign body reaction can be found from the middle dermis to the subcutaneous layer, and there is a fibrosis and lymphocyte clustering. After monofilament insertion there is a subtle but immediate lift evident.10
Threads for lifting can be either cogs or barbs, which mechanically lift the skin. The usual number of threads can be from one to five per side depending on what is being treated. Evidently, the type of thread to use is important – think about the treatment indications; is lift required or skin rejuvenation?
All types of threads can be used together or in conjunction with other treatment modalities for the best effects. Indeed, using barbed and cogged threads in combination with dermal fillers or fat grafting will give superior results by addressing the issue of volumetric change. Use of threads in conjunction with radiofrequency or microneedling for superficial rhytids will give improved results, as it may help to tighten excess skin to a limited degree.11
Thread lifting cannot address the issue of excess skin or volumetric change alone, although multiple monofilament threads can also give a degree of skin tightening.12
It is important to distinguish the difference between threads that are used for skin rejuvenation and threads that are used for lifting ptotic skin
- A patient may not want dermal filler treatment but would like to see an improvement in their appearance: Threads can provide a viable alternative to those individuals who would like improvement without use of dermal fillers. Spring threads can be used as an easy alternative in the nasolabial, malar and marionette regions. Spring threads are monofilament threads, which have been coiled around the introducing needle to make a spring shape. Monofilament threads can be used as an alternative to dermal fillers used for hydration and collagen stimulation.
- A patient has had dermal fillers to lift the skin and would like more of a lift: There is a limited amount of lift achievable using dermal fillers alone because they are only capable of adding volumeandgiveliftasasecondaryeffectbyredistributingthe volume in the face. For those patients who have undergone augmentation using the ‘8-point lift’ or ‘Tower technique’,13 a method of depositing dermal filler in a perpendicular depot, cogged and barbed threads can provide a further improvement of the appearance by giving additional lift.
Thread procedures often result in more downtime than that experienced when using injectables alone. For monofilament threads, the number of needle insertions necessary will inevitably result in bruising. For cogs and barbs, the entry point of the cannula or needle can be 16G, resulting in a visible entry area, and there can be irregularity of the skin over the thread tract for a couple of days. Patients differ with the amount of downtime they can tolerate, and what they perceive as downtime. Some patients will happily accept bruising and puckering for a number of days as being part of the procedure, whilst others will suffer a lack of confidence about their appearance if there are any visible signs of a procedure having taken place immediately after the treatment. Before discussing the possibility of using threads, it is important to know where your patient falls on this spectrum. Patient management post-thread procedure can be difficult if they do not fully grasp the risks of bruising, swelling and puckering following treatment. Unlike hyaluronic acid dermal fillers, the procedure cannot be easily reversed. It is important that all the possible complications and expected side effects are discussed, and the patient is given adequate time to weigh-up the information before deciding to go ahead. This is not a procedure suitable for consultation and treatment on the same day.
It is essential that the patient is able to tolerate the procedure. Pain thresholds and acceptance of treatment varies widely from person to person. As threads are more invasive than injectables, it is important that the patient is able to tolerate a modicum of discomfort during the procedure. The sensation of having the barbed and cogged threads tightened can be uncomfortable, and for some a distressing experience.
Realistic expectations are obviously essential. From my experience, the maximum amount of lift that can be achieved using barbs and cogged threads is around 1cm. If the patient has more to lift than this, then it may not be appropriate. If the patient does not want or cannot have surgery, a staged approach may be appropriate – using multiple threads in conjunction with other treatment modalities, which will result in an improvement but a compromised treatment outcome in comparison with a surgical outcome.
Threads for lifting do not work well on those with excessively lax skin, a large body habitus, thick skin and those with unrealistic expectations. Conversely, monofilament threads can be used to promote collagen stimulation in those with lax and crepey skin to promote skin tightening and texture improvement.14
Risks and complicationsAsymmetry: A patient will often examine their appearance in great detail after a cosmetic procedure so it is important to point out any pre-existing asymmetries. In the case of barbs and cogs, precision when inserting the threads and tightening when the patient is seated vertically, with patient participation so they can view the process in a hand mirror, is helpful in avoiding any potential problems with perceived asymmetry later on.
Rippling and puckering: This is a complication seen when using barbs and cogs. If the thread is tightened too much then the skin will ripple over the thread and cause visible folding. If the thread has been placed in the correct tissue plane then this will typically resolve itself in a few days. Sometimes slight ruching can be caused by oedema and the placement of local anaesthetic, swelling the tissues.15 It is important to be realistic when manipulating the thread and not to over tighten as this will not only lead to rippling, but also the tissues will drop again very quickly after a couple of days, thus leading to dissatisfaction for the patient and practitioner alike. Persistent dimpling can usually be corrected with manual manipulation several days post procedure.
Infection: From what I’ve seen, reported infection rates post-thread insertions are extremely low. All types of threads should be placed using an aseptic technique to reduce the risk of infection, which, practically speaking, translates as use of betadine or chlorhexidine preparation, use of a sterile field such as surgical drapes for cogs and barbs (although this is not necessary for monofilament and springs) and use of a sterile dressing pack and gloves.
Granuloma: Threads placed in a more superficial plane can lead to higher incidence of granuloma formation.16 In a study of 100 patients receiving either PDO or Prolene after minor breast biopsy, a buried knot eroded through the skin in 17% of PDO patients due to positioning and granuloma formation.
Thread loss: It’s essential when placing threads that when the thread is cut, the end will tuck back into the skin – protrusion of a thread through the skin is an infection and granuloma risk and
may cause distress to the patient. In the case of monofilament, if there is a protruding thread, the end should not be cut as with barbs and cogs, but grasped firmly and removed. It’s easy and cheap to remove a monofilament thread thus removing the risk of granuloma if the thread is placed too superficially. Barbed and cogged threads can only be removed with difficulty, if at all. If the end of a thread is left in a superficial plane then there is increased likelihood of granuloma formation.
Thread breakage: When first learning how to place cogs and barbs, breakage can be an issue. Typically this occurs during tightening of the PDO cogs and barbs as during placement the thread is protected by the needle or cannula. In the case of Silhouette Soft threads, the thread is not protected in this way and so the tissues must be carefully manipulated in order to avoid breakage during insertion and tightening.
Other potential side effects include:
- Haematoma formation17
- Nerve damage17
- Sensory impairment18
- Chronic pain18
- Palpability (more common in cogged threads but usually settles after several days)18
The use of threads provides the aesthetic practitioner with another potential treatment modality and can give more flexibility to reach patient expectations. It is important to select the correct patient before performing a thread lift and to be realistic about the potential treatment outcomes and potential complications of this versatile procedure.