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Thread-lift Sutures: Anatomy, Technique, and Review of Current Literature

Steven Halepas, DMD, Xun Joy Chen, MD, DMD, Elie M. Ferneini, DMD, MD, MHS,
MBA, FACS

PII: S0278-2391(19)31338-2
DOI: https://doi.org/10.1016/j.joms.2019.11.011
Reference: YJOMS 58975

To appear in: Journal of Oral and Maxillofacial Surgery

Received Date: 20 July 2019

Revised Date: 12 November 2019
Accepted Date: 12 November 2019

Please cite this article as: Halepas S, Chen XJ, Ferneini EM, Thread-lift Sutures: Anatomy, Technique,
and Review of Current Literature, Journal of Oral and Maxillofacial Surgery (2019), doi: https://
doi.org/10.1016/j.joms.2019.11.011.

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© 2019 Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial
Surgeons
Thread-lift Sutures: Anatomy, Technique, and Review of Current Literature

Steven Halepas, DMD (1)

Xun Joy Chen, MD, DMD (1)

Elie M. Ferneini, DMD, MD, MHS, MBA, FACS (2)

1: Resident, Department of Oral and Maxillofacial Surgery, New York Presbyterian/Columbia University
Medical Center, New York, NY

2: Director, Beau Visage Med Spa/Greater Waterbury OMS/University of Connecticut, Cheshire, CT

*Corresponding Author:
E. M. Ferneini, MD, DMD, MHS, MBA, FACS
Editor in Chief AJCS
Dentoalveolar Surgery Section Editor JOMS
Associate Clinical Professor, University of Connecticut
Private Practice, Greater Waterbury OMS
Medical Director, Beau Visage Med Spa
435 Highland Avenue, Suite 100
Cheshire, CT 06410
Tel: (203) 272-7700
Fax: (203) 574-2460
eferneini@yahoo.com
 Thread-lift Sutures: Anatomy, Technique and Review of Current Literature
S Halepas, XJ Chen, and EM Ferneini*

Abstract:

The use of thread-lift sutures as an alternative for traditional surgical rhytidectomy or neck lifting
is becoming more common practice among surgeons. The Silhouette Instalift TM is marketed as a
minimally invasive procedure that immediately lifts and tightens the skin while stimulating
fibroblast activation and the production of collagen. The evidence in the literature to support
thread-lift sutures for facial augmentation is limited with many studies having various degrees of
bias. Our intention is to educate the oral and maxillofacial surgeon on the thread lift suture
materials, techniques, relevant facial anatomy as well as review the current limited data that is
available. Using thread lift sutures for facial augmentation is a relatively low risk procedure that
surgeons familiar with facial anatomy can offer patients either as an alternative or in conjunction
with other facial aesthetic procedures such as facial fillers, neuromodulators, or surgical
procedures.

Introduction:

Facial cosmetic surgery procedures have a long and extensive history dating back to as early as
the 1890s when Robert Gersuny and J Leonard Corning recommended the injection of paraffin
for facial augmentation. The first textbook explicitly dedicated for facial cosmetic surgery is
believed to be that of Charles Conrad Miller in 1907 [1]. His second book published in 1924 has
many demonstrations of the traditional rhytidectomy procedure. According to the 2018 National
Plastic Surgery Statistics, in 2018 over 120,000 rhytidectomy procedures were performed and
over 2.6 million soft tissue fillers were administered in the United States [2]. The procedures
available for facial augmentation today range from minimally invasive procedures such as
neuromodulators, facial fillers, thread lifts, facial implants, and surgical procedures
(rhytidectomy, neck lift) [3, 4]. Facial fillers have increased exponentially in the last decade due
to their minimal downtime and relatively low complication risk compared to traditional open
surgery [5-7].

As patients elect for more minimally invasive rejuvenation procedures, the thread-lift technique
is an excellent option to have in the oral and maxillofacial surgeon’s arsenal. The use of thread-
lifting sutures has existed since the early 1990s and was often referred in the media as the “one-
hour lunch break lift” [8]. Over the years the materials the sutures consist of have progressed as
well with the addition of barbs and cones [9]. The thread-lift procedure has gained popularity
because of its low downtime and immediate potential aesthetic improvement. The Silhouette
Instalift TM is marketed as a minimally invasive procedure that immediately lifts and tightens the
skin while stimulating fibroblast activation and collagen production. The bi-directional cones on
the sutures hook onto the skin and provide the elevation that results in immediate tautness of the
skin [10]. The Silhouette Instalift TM has become one of the more common thread-lift brands
being used by surgeons performing these procedures. Whether this is due to the Silhouette’s
superior fundamental technology or due to marketing is still undetermined. The evidence in the
literature to support thread-lift sutures for facial augmentation is questionable. Limited data
exists on the subject as well as many studies having various degrees of bias. The authors have
found no large blinded controlled clinical trials describing the long-term effects of these
minimally invasive facial lift procedures.

Types of Threads:

The Aptos threads (manufactured by Chiramax ltd) are made of 2-0 polypropylene line with
dents that create sharp edges. Sulamanidze et al. early described placing a small incision in the
temporal area and several threads were pulled subcutaneously. After the lower thread and needle
emerged, the lower thread was cut off and the upper thread was sutured to the temporal muscle’s
fascia after moderate pulling. Sulamanidze et al. suggests Aptos methods are most effective in
the midface zone. Out of the 4580 patients, positive results were noted up to 1 year with no
complete relapse of the deformities noted even 3 to 4 years post operatively although the authors
attest to soft tissue sagging/weakening beginning about 1 year after the procedure [11]. Aptos
threads had a large cohort of complications with up to 20% of cases requiring revision.

Contour threads (Surgical Specialties Corp, Reading, PA) have unidirectional barbs and are
anchored to fascia [12]. Its use was described by Kaminer et al in 2008. 3 mm incisions were
made in the temporal hairline for the upper/midface lifting. Incisions were made posterior to the
sternocleidomastoid muscle for lower face lifting. The needle is then placed through the incision
into the subcutaneous plane and the needle was advanced in a zigzag pattern. The zigzag pattern
is believed to maximize the number of barbs that contact the skin. The needle then exits the skin
through and cut from the skin. The thread at the proximal portion near the incision is then
fixated to the deep fascia.

Multianchor suspension sutures were described by Eremia and Willoughby that contain a
monofilament resorbable suture with 5-9 evenly spaced knots [13]. The sutures are made with 2-
0 PDS or Maxon and 5-7 simple knots were placed into the suture. They compared open face
lifts and pure suspension lifts with no tissue excision. They noted that the minimally invasive
procedures results faded after 6-12 months. They did find that using the multianchor suspension
technique in conjunction with the open rhytidectomy demonstrated superior results as compared
to more aggressive open face lifts suggesting that these thread lifts may have a role in the open
technique.

The Silhouette sutures (Silhouette sutures, Kloster Methods, Inc, Corona, CA, USA) consist of 3-
0 polypropylene with about 9 knots roughly 10 mm apart. These knots contain poly-L-lactic acid
cones that are absorbable. The sutures are attached to a 20 cm straight needle and the thread is
about 37.3 cm in length. The absorbable cones are the reason the silhouette sutures are believed
to last longer than many of the alternative thread lift brands. The cones initiate an inflammatory
reaction by means of a foreign body response. The inflammatory process takes a long time to
degrade the cones while forming a fibrous capsule which aids in the retention of the suture to the
underlying connective tissue [13-15]. The Silhouette instalift differs from the other in the make-
up (18% PLGA and 82% PLLA) and the cones are bidirectional [16]. Poly-L-Lactic Acid
(PLLA) is a biodegradable synthetic polymer that stimulates collagen production and is the
principle component in Sculptra ®. PLLA can provide long lasting effects with the duration of
Sculpra ® reported up to 3 years.

Anatomical Considerations:

A thorough understanding of facial anatomy is a critical component of any facial esthetic

procedure. Anatomical understanding of the signs of aging must be incorporated into patient
evaluation, planning, and treatment to allow the provider to reverse those signs of aging [17].

The anatomy of the face is best described in a layered fashion from superficial to deep and
includes the following: skin, subcutaneous fat, superficial musculo-aponeurotic system (SMAS),
deep fat, and deep fascia. The skin layer is divided into epidermis and dermis. The epidermis is
the outermost layer consisting of keratinizing stratified squamous epithelium and is anchored to
the underlying dermis by hemidesmosomes at the basement membrane. This dermal-epidermal
junction provides the mechanical support for the epidermis and acts as a barrier. The underlying
dermis consists of connective tissue composed of collagen, elastin, pilosebaceous units, and
includes a complex neurovascular network. The dermis gives the skin its pliability, elasticity,
and tensile strength. Variation in the thickness of the dermis determines regional variation in
skin thickness in different areas of the face [18].

The subcutaneous fat is immediately deep to the dermis and is a discrete anatomic plane
superficial to the superficial musculoaponeurotic system (SMAS) [19]. The subcutaneous fat
can be further subdivided into two different arrangements with different substructures and
characteristics. In the medial and lateral midface, temple, neck, forehead and periorbital areas,
the adherence of the underlying structures to the skin through the subcutaneous fat is loose and
easily separated from the skin. In the perioral, nasal, and eyebrow regions, collagen and muscle
fibers insert directly into the skin and connect the skin to the underlying muscles of facial
expression and is classified as “fibrous”. The superficial fat is partitioned into distinct anatomic
compartments consisting of nasolabial, jowl, cheek, forehead/ temporal, and orbital
compartments. The nasolabial fat compartment lies medial to the cheek fat and overlaps the jowl
fat. The jowl fat is adherent to the depressor anguli oris, bound medially by the lip depressors,
and inferiorly is a membranous fusion with the platysma muscle around the mandibular‐
cutaneous ligament. The cheek fat compartments contain three distinct compartments: the
medial, middle, and lateral temporal cheek fat. The medial cheek fat is a small compartment
lateral to the nasolabial fold. The middle cheek fat is a larger compartment found anterior and
superficial to the parotid gland. The lateral cheek fat compartment lies immediately superficial
to the parotid gland and connects the temporal fat to the cervical subcutaneous fat. There is
heterogeneity of the facial fat in these compartments, with each compartment having different
adipocyte morphology and extracellular matrix compositions which provide unique mechanical
and histochemical properties.

The SMAS is an organized fibrous network making up the superficial fascia of the face and neck
and connects the facial muscles with the dermis. This layer separates the subcutaneous fat from
the parotid‐masseteric fascia and facial nerve branches. It extends from the malar region
superiorly to become continuous with the galea, inferiorly to become part of the platysma, and
laterally to invest in the parotid fascia over the parotid gland. All the facial muscle motor nerves
run deep to this plane, thus dissection deep to this layer increases the risk of facial nerve injury.
When this layer is stretched or pulled, it moves the entire lateral face in the desired vector, thus
allowing the face to move more as a unit [20]. In the midface, the facial mimetic muscles are
deeper than in the upper face. The platysma originates in the neck as a paired muscle that
crosses the mandibular border and inserts into the dermis and subcutaneous tissues of the lower
lip and chin. All facial mimetic muscles are innervated by branches of the facial nerve from the
deep surface except for the mentalis, buccinator, and levator anguli oris [21].

Patient Selection:

As with all elective cosmetic procedures, patient selection is paramount in determining operative
success. Patients who are suitable for lifting operations should have mild skin laxity, mild fat
pad prolapse, and superficial rhytids (Figures 1 & 2). Patients with advanced facial lipoatrophy,
excessive laxity of the skin that requires removal, or advance cutaneous or muscular prolapse, as
well as those who request immediate results, or exaggerated lifting like traditional lifting, are
generally not suitable for the thread lift procedure. Given the limited data available the most
successful results are somewhat subjective based on providers previous experience but the most
favorable outcomes with thread lifting procedures were reported among patients who had low
body fat percentage, minimally to moderate jowls, and prominent bony projections [22]. The
most successful areas seen were in the tear trough/malar fat pads, and nasolabial folds [23].
Obese patients tend to have less than favorable results, which could be explained by the complex
fat distribution in the face and the density that these patients have. To select the appropriate
thread and suture technique for each patient, the surgeon should focus on the specific patient
defect and primary area of patient concern [24].

Technique

Minimally invasive thread lift procedures can be done under local anesthesia, intravenous
sedation, or general anesthesia. The skin is carefully prepped and draped. The incision
site/insertion area should be injected with local anesthesia, usually 1% lidocaine with
epinephrine, for analgesia and hemostasis. Perioperative antibiotics prophylaxis is usually not
recommended. In fact, antibiotic prophylaxis in cosmetic surgery is still debatable in the
literature with more data to support a single one time dose peri-operatively or no antibiotics at all
[25].

The silhouette instalift is performed in the subcutaneous level while some thread lift procedures
are performed in the deeper planes. We describe the instalift procedure performed by
manufacture protocol:

An 18G needle is used to create an entrance to the skin and then the suture needle is placed
perpendicular to the skin and is advanced about 5 mm, which is demarcated by a black line on
the needle. At this point, the needle is redirected in the subcutaneous plane and advanced in the
pre-determined vector. Figure 2a and Figure 2b show a patient marked with the intended
vectors. The actual vector selection is subjective and patient specific. The vectors are
determined based on the desired movement of the tissues and how much can mobilized during
examination. The vectors are always placed in a superior-lateral direction but the length of each
is dependent on how much pull and in what direction the soft tissue needs to be. Most often
anywhere between 2-6 sutures are placed on each side to treat the midface, jawline, and neck.
The authors recommend vertical vectors to treat the midface and horizontal ones to treat the
neck. The thread as seen in Figure 1 contains two needles. One needle is inserted at the middle
mark and advanced to the superior lateral mark. The second needle on the opposite end of the
thread is inserted in the middle mark and advanced inferior medially to the mark by the corner of
the mouth. Tension is then applied on the medial part of the suture. The skin is given time to
relax to see if additional tension is needed. Once the desired effect has been achieved, the
sutures are pulled slightly and excess is cut to allow the end of the suture to end below the skin
level.

Discussion:

The most common complication is consistent with most surgical procedures such as swelling and
bruising. Skin dimpling or buttoning are also potential adverse events that can occur. Reported
complications have been minimal but can include anywhere from infection, pain, ecchymosis,
paresthesia, and inadequate cosmetic result. Commonly providers have reported thread
disruption, thread migration, or thread exposure that may require re-treatment.

Complications from traditional rhytidectomy range from hematoma formation to nerve damage.
Nerve injury with rhytidectomy has been reported at rates of 0.7-2.5% [26]. Other risks with
rhytidectomy include poor scar positioning resulting in ear deformities, hypertrophic or keloid
scarring, contour deformities, or flap necrosis. Risk of damage to the facial nerve is thought to
be much lower in thread lifts as compared to traditional rhytidectomy. A recent study
demonstrated risk of damage to vessels, nerve or glands has been reported to be (0.02%) out of a
study with 6098 patients [27]. Given the limited data on thread lifts, it is difficult to exactly
compare the two rates. From a surgical standpoint the hypothetical risk is much lower with the
thread lift as compared to a rhytidectomy that requires the use of a scalpel and often
electrocautery.

The long-term effects of these minimally invasive procedures have been explored but the data is
limited. Numerous studies tried to qualify the longevity of these procedures using patient
satisfaction of various time periods post-operatively. Other studies defined longevity of the
facial rejuvenation by clinical exam either by the original surgeon or a surgeon blinded to the
surgical procedure. All these techniques impose their own bias and therefore the findings are
restricted. It is useful, however, to have some references when describing the procedure to
patients and the overall “success” rate. De Benito et al. described overall patient satisfaction
over an 18-month period post operatively with the use of silhouette sutures [13]. Another study
by Kamier et al. found that on average of 11.5 months post-operatively 72% of patients felt that
their barbed suture lift met their expectations. Clinical effects were seen up to 16 months post-
procedure and 75% of them would recommend the procedure to a friend [12].

Rachel et al. performed 29 minimally invasive thread suturing lifts over 17 months in 2010 with
contour threads. They reported that 45% returned complaining of early skin relaxation within 6
months of the procedure and 69% reported adverse events such as pain, dimpling, visible
threads, paresthesia or foreign body reactions [28]. Garvey et al. described a study involving 72
patients who underwent the contour thread procedure and note that 42% of these patients
underwent re-treatment on average of 8 months following the procedure [8].

Villa et al. published a paper in 2008 performing a review of the current literature on barbed
sutures. The authors reported minimal evidence and described the technique as “in its infancy”
but continued with it has “potential useful benefits” [9]. Gulbitti et al. preformed a systematic
review a decade later in 2018 and determined that little evidence has been added into the
literature that encourages the use of these minimally invasive thread lift procedures [29].

Conclusion:

With traditional rhytidectomy patients can still expect good results at least 12 months following
the procedure [23]. With the non-invasive thread lift procedure results can vary from 6-18
months. The thread lift suture procedure may be advantageous to patients who are looking for at
least a short-term facial augmentation procedure that has relatively low risk and low-down time.
It also might be a good stepping stone prior to traditional open face lift surgery. The use of these
thread sutures may also prove to be beneficial in conjunction with open face lift surgery.
Surgeons who perform these thread lift procedures more routinely are finding greater success
[30] . Abraham et al. explained the fundamental flaw that all the thread lift sutures share and that
is that they only allow suspension of the facial soft tissue across a plane rather than cause any
true volumetric changes such as with fat augmentation or tissue excision [31]. Whether the
PLLA found in the Silhouette Instalift cones can stimulate collagen product to cause enough
volumetric changes is still not well explored but is a step in the right direction as compared to the
previous thread-lift materials.

Acknowledgments

The authors have no financial interest with Silhouette Instalift or Sinclair. The authors are not
endorsing the use of Silhouette Instalift over other thread-lift company but disclose more
familiarity with this particular brand.

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Figure 1. Silhouette thread

Figure 2a and 2b. Markings demonstrating intended vector trajectory for the Silhouette Insta-lift
thread sutures. The first mark is usually at to the marionette lines. Using a ruler, a second mark
is made 5.5 cm from the initial mark going towards the tragus. A third mark is made 5.5 cm
from the second mark towards the hairline.

Figure 3. A 62-year old female immediately before (above) and immediately post operatively
(below) undergoing the Instalift procedure with Silhouette sutures.

Figure 4. A 67-year old female immediately before (above) and immediately post operatively
(below) undergoing the Instalift procedure with Silhouette sutures.

Figure 5. Patient from figure 4 at 5 months follow up.