LETTERS AND COMMUNICATIONS

Jeremy C. Davis, MD Department of Dermatology

Karynne O. Duncan, MD, Inc., Dermatology University of Southern California
St. Helena, California Los Angeles, California

Richard G. Bennett, MD The authors have indicated no significant interest with

Department of Dermatology commercial supporters.
University of California The authors thank Eo Trueblood, Stream Studios Medical
Los Angeles, Los Angeles, California Illustration for the illustrations in this article.

Lower Facial Rejuvenation Using Absorbable Casting Barbed Thread

Over the last few decades, one of the main treatments
of wrinkles has been conventional superficial musculo-
aponeurotic system (SMAS) facelifts.1 However, the
conventional method has several limitations. There-
fore, we introduce a minimally invasive lifting method
using absorbable barbed thread made by casting
methods. The objective of this study is to analyze the
efficacy and safety of minimally invasive nonsurgical
thread (MINT LIFT) for lower facial rejuvenation and
improving deep nasolabial folds.
bidirectional barbs on both sides to grab and secure the
soft tissue that needs to be remodeled (Figure 1).
All procedures were performed under monitored
anesthetic care with local anesthesia (0.5% lidocaine
hydrochloride with 1:100,000 epinephrine) and
tumescent solution infiltration (1 mL epinephrine 1
mg/mL, 1 ample hyaluronidase 1,500 IU, 50 mL
lidocaine 2% 20 mg/mL, 12.5 mL sodium bicarbonate
8.4% 1.68 g/20 mL, and normal saline 1 L).

Sixty-one patients were enrolled (3 men and 58
women), all of whom had a rating of 3 or 4 on the
Wrinkle Severity Rating Scale (WSRS). Our study was
performed under the approval of the institutional
review board. We performed a 24-week, single-center,
single-arm, pre-post test design, open clinical study
among these patients with deep nasolabial folds and
lower facial drooping.
The provided absorbable casting barbed suture is the
first polydioxanone-based, absorbable, barbed suture by
noncutting technology. It contains multiple, diversified,
The exit points were designated on a straight line, which
connected the alar base and the angle of the mandible
(Line I). We also drew 2 horizontal, parallel lines, 1 from
the alar base (Line II) and another from the oral com-
missure (Line III). Then, we supposed 4 points. The point
of intersection between Lines I and III was named Point
B, the midpoint between the alar base and Point B was
Point A, the angle of the mandible was Point D, and the
midpoint between Point B and D was Point C (Figure 2).
The efficacy and safety of the procedure were eval-
uated using several scales: (1) comparison of the

Figure 1. (A) The classical absorbable, barbed suture by cutting technology. (B) The polydioxanone-based, absorbable,
barbed suture by noncutting and casting technology. It contains multiple, diversified, bidirectional barbs.

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 LETTERS AND COMMUNICATIONS

Figure 2. Schematic preoperative design for comparison of the distance from a baseline to some given points.

distance from a baseline to some given points
(before procedure and immediately after pro-
cedure), (2) degree of improvement in the WSRS
score on the 4th, 8th, and 24th weeks as evaluated
by the operator and the independent evaluator, (3)
degree of improvement in the GAIS (Global Esthetic
Improvement Scale) score on the 24th week as
graded by the operator and the patients, and (4)
complications during the study. Statistical analyses
included the paired t-test, Wilcoxon signed rank
test, and McNemar test.
ferences in the distance between given points (before
procedure and immediately after procedure) were
checked. On the right side, the difference was 0.41 6
0.20 cm for Point A, 0.83 6 0.23 cm for Point B,
0.78 6 0.24 cm for Point C, and 0.48 6 0.25 cm for
Point D. On the left side, the difference was 0.42 6
0.24 cm for Point A, 0.81 6 0.20 cm for Point B,
0.79 6 0.15 cm for Point C, and 0.49 6 0.29 cm for
Point D (Figure 2). There were improvements on all
points, and Points B and C especially showed
a remarkable lifting effect (Figure 3).

The effectiveness of the procedure was evaluated The preoperative baseline WSRS, as measured by the
according to several categories. First, immediate dif- operator, was 3.21 6 0.41. The degree of improvement in

Figure 3. Intraoperative photographs of the face of a subject. (A) Note the difference of the right side, which is lifted
by minimal-invasive nonsurgical thread technique, and the left, nonlifted side. (B) Both cheeks are markedly lifted.

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 LETTERS AND COMMUNICATIONS
Figure 4. Representative photographs of the nasolabial folds and lower face of 2 subjects who received minimal-invasive
nonsurgical thread technique (A and C) before and (B and D) after 24 weeks.
the WSRS was 21.23 6 0.42 on the 4th week, 21.25 6
0.43 on the 8th week, and 21.16 6 0.37 on the 24th
week. The baseline WSRS and the degree of improvement
of the WSRS, as measured by the independent evaluator,
were 3.30 6 0.45 (baseline), 21.56 6 0.43 (4th week),
21.41 6 0.48 (8th week), and 21.20 6 0.45 (24th
week). The degree of improvement, as measured by both
the operator and independent evaluator, was statistically
significant (p < 0.05).
The GAIS on the 24th week were also determined by the
operator and the patients. The final GAIS score on the
24th week was 1.85 6 0.44 by the operator and 1.84 6
0.73 by the patients. Both GAIS scores were approxi-
mately 2, which corresponds to “much improved”
(Figure 4).
With regard to the safety and complication of our
technique, we encountered only some minor,
procedure-related complications during the study. All
these complications subsided spontaneously, without
any aggressive intervention.
For several decades, the demand for a more effective,
less time-consuming, and longer-lasting method for
facial rejuvenation has increased.2,3 In this study, we
performed a minimally invasive rejuvenation procedure
using absorbable casting barbed thread to improve
lower facial contour and deep nasolabial folds.
886 DERMATOLOGIC SURGERY
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The barbed thread in our study was especially different
from the existing in that it was neither cut nor knotted.4
It was the first absorbable monofilament barbed suture
designed by patented noncutting technology. When
inserted, the cogs created sustaining supports against
the direction they was inserted and was expected to
have mechanobiological stimulation to the surrounding
tissues, promoting regeneration of skin tissue.
According to this study, the immediate post-
procedure lifting effect was approximately 0.4 to 0.8
cm for the given points. Furthermore, more than 90%
of the enrolled patients maintained the lifting effect
until the 24th week in the WSRS or GAIS of the
operator, evaluator, and patients. These results
indicate that the procedure is an effective technique
for facial rejuvenation.
Regarding the side effects of the procedure, there were
only a few minor complications, and no significant
problems were observed in our investigation. The
complications that we encountered were pustule forma-
tion, pain, swelling, subjective discomfort of tightness,
and skin dimpling. These side effects were usually self-
limited.
This study showed that the procedure using the
absorbable casting barbed thread for the correction of
nasolabial folds and lower facial drooping is ultimately

a favorable technique. It has many advantages over
other invasive and noninvasive rejuvenation proce-
dures, including limited scarring, relative safety, rapid
recovery, and a persistent effect. In addition, a high
degree of patient satisfaction was achieved as well.
In conclusion, the minimal-invasive nonsurgical
thread technique offers an effective, minimally
invasive, and safe method to improve nasolabial
folds and lower facial drooping without any
significant postprocedure morbidity or
complications.
References
1. Kaminer MS, Bogart M, Choi C, Wee SA. Long-term efficacy of
anchored barbed sutures in the face and neck. Dermatol Surg 2008;34:
1041–7.
2. Garvey PB, Ricciardelli EJ, Gampper T. Outcomes in threadlift for facial
rejuvenation. Ann Plast Surg 2009;62:482–5.
3. Sardesai MG, Zakhary K, Ellis DA. Thread-lifts: the good, the bad, and
the ugly. Arch Facial Plast Surg 2008;10:284–5. 4.
Anaphylactic Shock After Injection of Foamed Sodium Tetradecyl Sulfate
The treatment of varicose vein with sclerosing agents
has been gaining enthusiasm since the great efficacy of
foam sclerotherapy with detergent sclerosants has
been documented. It has become one of the most
commonly performed procedures in dermatology
clinics worldwide.1
Sclerotherapy has been reported to be associated with
a few minor complications. Fatal allergic reactions are
exceedingly rare.1 The authors herein reported a case
of anaphylaxis after injection of sodium tetradecyl
sulfate (STS).
A 56-year-old woman visited the hospital because of
severe varicose veins in her left leg associated with
a stasis ulcer for many years. She had been previously
healthy and was taking no medications. She had
anaphylactic shock after taking multiple drugs,
including acetaminophen, ketoprofen, and sulfame-
thoxazole/trimethoprim. She did not smoke, drink
alcohol, or use illicit drugs. Duplex ultrasound
© 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
4. Beer K. Delayed complications from thread-lifting: report of
a case, discussion of treatment options, and consideration of implications
for future technology. Dermatol Surg 2008;34:1120–3.
Woon Il Baek, MD
Woo Seob Kim, MD
Department of Plastic Surgery, Chung-Ang
University College of Medicine
Seoul, Korea
Joon Hyuk Suh, MD
Beom Joon Kim, MD
Department of Dermatology, Chung-Ang
University College of Medicine
Seoul, Korea
The authors have indicated no significant interest with
commercial supporters.
W.I. Baek and J.H. Suh contributed to this work equally as
the first authors.
W.S. Kim and B.J. Kim contributed to this work equally as
corresponding authors.
examinations revealed a pronounced reflux signal in
the left saphenofemoral junction, as well as the great
saphenous vein. She then underwent duplex-guided
foam sclerotherapy with STS, foam of which was
generated by the Tessari technique with the liquid-to-
air ratio of 1:4. About 10 mL of 3% STS (Fibro-Vein;
STD Pharmaceuticals, Hereford, United Kingdom)
foam was injected into her great saphenous vein under
duplex guidance at the mid-thigh and calf area. Soon
after the injection, she reported shortness of breath
and generalized itchy erythema, which was found to
be urticarial wheals. She then became unconscious
and hypotensive (blood pressure 60/40 mm Hg).
Emergent resuscitation began immediately. Oxygen,
a subcutaneous injection of 0.5 mg epinephrine, an
intramuscular injection of 2.5 mg dexamethasone,
and 40 mg diphenhydramine were administered.
Five minutes later, the patient was awake and
successfully carried out an order. Her blood pressure
increased to 92/60 mm Hg. Her skin reaction subsided
10 hours later.
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