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ince the introduction of thread-lift sutures, tissues by means of a minimally invasive closed
its application has gradually spread among procedure. Its application is claimed to be easy
many cosmetic medical specialists (such as after proper training, and it is suggested to be a
plastic surgeons and maxillofacial surgeons) and good alternative for surgical lifts because it is a
cosmetic doctors (medical doctors and dentists significantly less invasive procedure. Many col-
specialized in noninvasive aesthetic treatments leagues used the technique in the early 1990s
such as botulinum toxin type A and filler injec- but stopped doing so because of disappointing
tions), with the main indication of lifting sagged results. Currently, more and more cosmetic doc-
tors offer the procedure; this is the next group
From the Department of Plastic Surgery, University of Gron- of cosmetic treatment providers that will experi-
ingen, University Medical Centre Groningen; Amsterdam ence the true value of thread-lift sutures. The cos-
Plastic Surgery; and Bergman Clinics; the Department of metic industry has flooded the market with a vast
Plastic Surgery, AZ Groeninge; and the Department of Max-
illofacial Surgery, University of Verona.
Received for publication July 19, 2017; accepted October 4, Disclosure: The authors have no financial interest
2017. to declare in relation to the content of this article. No
Copyright © 2018 by the American Society of Plastic Surgeons funding was received.
DOI: 10.1097/PRS.0000000000004101
www.PRSJournal.com 341e
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • March 2018
array of different types of so-called thread-lifting We reviewed the literature to evaluate the
sutures. Substantial amounts of marketing budget same clinical parameters as reported in the review
have been allocated by these companies to “train” article by Villa et al. 11 years ago: (1) the type of
physicians in this procedure. These commercial suture, (2) the efficacy and longevity of the effect,
incentives in combination with enthusiastic cos- and (3) the adverse events. However, we did
metic professionals are mainly responsible for the not limit our search to midface elevation alone;
extensive spread of this supposed minimally inva- instead, we included all articles on soft-tissue lift-
sive lifting procedure. ing in the face.
In 2006, Villa et al. published a review arti-
cle concerning the use of thread-lift sutures
RESULTS
for midface elevation.1 The authors concluded
that the technique was still in its infancy, but The initial search with all search terms
that it had the potential to become a useful and resulted in 188 articles. After filtering the dupli-
effective procedure as further innovations were cates and the articles about open procedures, a
made. As 11 years have passed, and based on total of 41 articles remained (Fig. 1). Of these, the
personal experience with thread-lift sutures, review articles, case reports, and letters to the edi-
we were curious about the real scientific state tor were subsequently excluded. This resulted in
of the art on the use of thread-lift sutures and 24 articles to be included in further search and
therefore performed a systematic review on this review (Fig. 2). During a more detailed review of
topic. these articles, any study that dealt with nonbarbed
sutures, such as Vicryl on a Gore-Tex patch, was
also eliminated. Also, articles that did not men-
PATIENTS AND METHODS tion a follow-up time were filtered out. Finally,
A systematic review was performed accord- 12 articles were considered for use in this review,
ing to Preferred Reporting Items for Systematic of which five dated from before 2006 and were
Reviews and Meta-Analyses guidelines using the already discussed in the review article by Villa et
PubMed database and the Medical Subject Head- al.1 As it was not our intention to replicate the
ings search term “Rhytidoplasty.” “Rhytidoplasty” findings reported by Villa et al., we focused on
is defined as plastic surgery performed, usually the most recent seven additional included articles
by excision of skin, for the elimination of wrin- (Table 1).2–8
kles from the skin. The term was introduced in
1989. The following entry terms are included by Type of Suture
this Medical Subject Headings term: “facelift,” Four of five studies reviewed by Villa et al.
“facelifts,” “face Lift,” “Face Lifts,” “Lift,” “Face,” used Aptos (Aptos International, Tbilis, Geor-
“Lifts,” “Platysmotomy,” “Platysmotomies,” “Rhyt- gia) threads for closed suspension.1 These Aptos
idectomy,” “Rhytidectomies,” “Platysmaplasty,” threads are no longer described in recent studies.
and “Platysmaplasties.” Instead, Contour Threads (Angiotech Pharma-
The Medical Subject Headings term “Rhyti- ceuticals, Inc., Vancouver, British Columbia, Can-
doplasty” was combined with the following search ada) are being described (in four of six studies).
terms “barbed suture,” “Thread lift,” “APTOS,”
Aptos Threads and Woffles Threads
“Suture suspension,” “Percutaneous,” and “Sil-
The Aptos threads were described by Sula-
houette suture.” RefWorks (ProQuest, Ann Arbor,
manidze et al. in 2002 and are made of 2-0 poly-
Mich.) was used to filter duplicates. Three of the
propylene line with dents provided during the
authors (H.A.G., B.C., and B.L.) performed the
manufacturing process, thus creating slant edges
search independently.
with sharp ends.9 Woffles threads were described
As we focused on closed procedures, we elimi-
by Wu.10 We did not find any recent literature
nated any article describing open procedures in
describing long-term results of these sutures.
combination with thread-lift sutures during a first
search. Subsequently, all review articles, technical Contour Threads (Nonresorbable)
reports, case reports, and letters to the editor were Contour Threads were approved by the U.S.
withdrawn in a second search. Eventually, all arti- Food and Drug Administration in October of
cles dealing with nonbarbed sutures, such as Vic- 2004. They consist of a 25-cm length of 2-0 poly-
ryl (Ethicon, Inc., Somerville, N.J.) and Prolene propylene suture with a central 10-cm segment of
(Ethicon) with Gore-Tex (W. L. Gore & Associ- 50 unidirectional helicoidally configured barbs
ates, Flagstaff, Ariz.), were excluded. (Surgical Specialties Corp., Reading, Pa.).
342e
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 141, Number 3 • Review of Thread-Lift Sutures
343e
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Table 1. Overview of the Search Results*
344e
Specialty of the
Reference Author Device No. of Patients Follow-Up Evaluation Results Complications Disclosures
Eremia and Dermatologist Multianchor 20 patients of which 6–12 mo Preoperative and With pure suspension No significant Nondisclosure
Willoughby, suspen- 14 underwent postoperative lift; by 6 mo, correc- complication
2
2006 sion pure, “no- photographs tion started to fade; by
suture skin-excision,” 12 mo, 100% of initial
suspension lifts correction for jowls,
and 80 to 100% for
midface, appeared lost;
recovery time was 2–4
days
Kaminer Dermatologist Contour 20 patients were Minimum Anonymous Satisfaction, 6.9; over- Bruising, swelling, Grant from
et al., 20083 Threads mailed, 12 6 mo satisfaction survey all improvement, 4.6 pinching Angiotech
replied (scale, 1–10) (company
makes Con-
tour Threads)
Abraham Otolaryngologist Contour 33 patients, of which 12–31 mo Blinded surgeon Overall aesthetic Skin dimpling, Dr. Williams is
et al., 20094 Threads 10 underwent scoring an improvement 0.2–0.5, visible knots a shareholder
thread lift alone; aesthetic grading which implicates in the New
23 in combination scale minimal improvement England Laser
with other pro- (scale, 0–3) and Cosmetic
cedure; control Surgery
group Center
Garvey et al., Plastic surgeon Contour 72 patients, 8.4 mo Chart review 30 of the 72 patients Swelling, ecchy- Unknown
20095 Threads of which 55 (42.3%) underwent mosis, infection,
underwent a some form of revision thread extru-
pure closed surgery at an average of sion, palpable
procedure 8.4 mo threads, contour
irregularity, and
recurrent laxity
Rachel et al., Plastic surgeon Contour 29 patients, 1–25 mo Nonblinded review 50% recurrence of lax- 20 patients (69%): Nondisclosure
20106 Threads of which 18 (average, of preoperative ity within 6 mo; 14% intractable pain,
underwent a 12 mo) and postoperative already in the first 8 wk; dimpling, visible
pure closed photographs by 17 patients required and palpable
procedure surgeons and second procedure dur- thread, thread
patients ing follow-up period extrusion, par-
esthesia, foreign
body reaction
de Benito Maxillofacial Silhouette 316 patients, 22 of Maximum Preoperative and The results are relatively 42 patients Dr. de Benito
et al., 20117 surgeon Sutures which underwent 3 yr postoperative long-lasting with high (13.3%): moder- received
a combined mid- (average photographs levels of satisfaction ate pain in the consulting
face suture lift 18 mo) among patients and temporal area fees from
and endoscopic surgeons (7%), visible Silhouette Lift
forehead lift or dermal pinching company
upper and/or (3.5%), hema-
lower blepharo- toma in the
plasty or neck lift temporal area
(1.3%), asym-
metry (0.6%),
suture palpabil-
ity (0.3%)
Plastic and Reconstructive Surgery • March 2018
(Continued)
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 141, Number 3 • Review of Thread-Lift Sutures
interest with
The most frequent No significant human body, and also completely biodegrad-
commercial
Disclosures
supporters
able, that such applications have been developed.
De Benito et al. used Silhouette sutures.7 They
consist of a 37.3-cm length of 3-0 polypropylene
suture with a central 8-cm segment of nine knots
at approximately 10-mm intervals. Each knot is
which occurred
patients (6.5%)
postprocedure
asymmetry was
(93.5%); mild
(90.3%); mild
intercalated with an absorbable cone of poly-
Complications
in 29 patients
observed in 2
complication
was bruising,
swelling was
observed in
28 patients l-lactic acid, making up a series of eight engaging
elements.
Polydioxanone Threads (Resorbable)
Suh et al. used resorbable knotless polydioxa-
none threads.8 Cog polydioxanone threads have
tory for the remaining 4
considered unsatisfac-
lifting was evaluated as barbs, which stick to tissues when inserted and
(25.8%), and poor for
including 19 patients
1 (3.2%) patient(s);
9 (29.0%), fair for 8
(absorb-
threads
polydi-
Knotless
able)
Dermatologist
Adverse Events
Table 1. Continued
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Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • March 2018
and foreign body reaction).6 Other complications improvement rate.3,7 Eremia and Willoughby
described were infection and mild asymmetry.5,7,8 showed an improvement of facial laxity up to 16
Serious adverse events, including injury to the months after the procedure, with the most favorable
facial nerve, have not been reported. effect seen in the tear trough/malar fat pads and
nasolabial folds.2 However, it should be noted that
this research group received a grant from Angio-
DISCUSSION tech, the company that manufactures the Contour
This systematic review regarding the use of Threads. Also, de Benito et al. showed that thread-
thread-lift sutures for closed minimally invasive lifting procedures provide stable results with a high
lifting procedures in the face clearly demonstrates level of satisfaction among patients and surgeons.7
that, despite promising results suggested by pre- However, we have to also realize that de Benito et
liminary results in the past, there is no substantial al. received consulting fees from the Silhouette Lift
scientific evidence that thread-lift sutures have a company for travel and hotel expenses associated
long-lasting effect. Eleven years ago, Villa et al. with providing lecture and surgery workshops for
concluded that the thread-lift suture lift technique the company.
was still in its infancy but suggested that it had the Atiyeh et al. assessed in a review article not only
potential to become a very useful and effective evidence-based efficacy but also the general views
clinical tool as further innovations were made.1 expressed in the literature arising from empirical
However, they also stated that future research observation and opinion.11 They conclude that
concerning the thread-lift suture should consider a surgical approach to redistribute the different
objective, standardized photographic analysis of anatomical layers of the face by standard open or
facial suspension at fixed intervals postoperatively endoscopic face lifts cannot be replaced by simply
in a double-blinded fashion. suspending ptotic tissue with threads like a mari-
Unfortunately, we have found only one such study onette. In our review, we did not include articles
using a control group for evaluation and a blinded about nonbarbed sutures, as one could expect an
surgeon scoring an aesthetic grading scale after the even less long-lasting effect with these sutures.
use of thread-lift sutures.4 The authors of this study The overall reported rate of serious complica-
concluded that the thread-lift provides only limited tions with thread-lift suture is low. There is, how-
short-term improvement that may be largely attribut- ever, the potential for detrimental complication
able to postprocedural edema and inflammation. of nonreversible scarring after an infection with
Most other studies demonstrated only a lim- threads. Possible long-term damage to the deli-
ited effect and/or limited longevity. A study by cate superficial musculoaponeurotic system layer
Suh et al. showed that the thread lift was effec- caused by repetitive scarring must also be consid-
tive for uneven facial textures, slack midface, and ered, as our first objective is to not do any harm
minimal to moderate jowls in selected patients.8 to precious tissues. Cosmetic doctors using these
However, the lifting effect was evaluated as fair to techniques are mainly nonsurgeons who have not
poor in 45 percent of patients. Eremia and Wil- been “brought-up” with the principles of sterile
loughby showed that correction started to fade by techniques, and learn these procedures often in
6 months, and 80 to 100 percent of the correction 1-day industry-sponsored courses.
appeared lost by 12 months.2 Garvey et al. found a Despite the lack of evidence for long-lasting
high rate of revision procedures following a Con- results of closed thread-lift suture lift, its use is
tour Thread lift; in addition, the time to revision currently still very popular, probably driven by
was found to be short.5 They concluded that the industry and money-driven cosmetic physicians
results achieved by the Contour Thread lift were promising face-lift results without surgery, a fairy
subtle and short-lived and advocate that patients tale story many potential clients for facial rejuve-
be educated about these limitations. A study by nation wish to believe. Also, because these clients
Rachel et al. similarly showed early recurrence have already been successfully treated in the past
and a high incidence of adverse events after Con- by their cosmetic doctor with botulinum toxin
tour Thread placement and therefore do not rec- type A and fillers, many of them also believe in the
ommend this technique.6 If patients would really next step offered by them: the nonsurgical face
understand this, they probably would not pay lift using a closed thread-lift suture lift.12
such an amount of money for a closed thread-lift However, there may be significant advan-
suture lift that lasts for only a few months. tages when thread-lift sutures are combined with
Thus far, only two studies showed promis- an open procedure.13,14 For example, the multi-
ing results with a high satisfaction and overall anchor thread-lift suspension sutures distribute
346e
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 141, Number 3 • Review of Thread-Lift Sutures
tension more evenly among the lifted tissues.15 2. Eremia S, Willoughby MA. Novel face-lift suspension suture
The microimbrication of a dissected layer, like the and inserting instrument: Use of large anchors knotted into
a suture with attached needle and inserting device allow-
superficial musculoaponeurotic system, is subse- ing for single entry point placement of suspension suture.
quently locked by the overlying skin/dermal layer, Preliminary report of 20 cases with 6- to 12-month follow-up.
thereby locking the “lift effect.” A variant of the Dermatol Surg. 2006;32:335–345.
thread-lift suture, the V-lock suture, is nowadays 3. Kaminer MS, Bogart M, Choi C, Wee SA. Long-term efficacy
routinely used in closing wounds without knitting. of anchored barbed sutures in the face and neck. Dermatol
As such, thread-lift sutures really can have a defi- Surg. 2008;34:1041–1047.
4. Abraham RF, DeFatta RJ, Williams EF III. Thread-lift for
nite role in the future. facial rejuvenation: Assessment of long-term results. Arch
Facial Plast Surg. 2009;11:178–183.
5. Garvey PB, Ricciardelli EJ, Gampper T. Outcomes
CONCLUSIONS in threadlift for facial rejuvenation. Ann Plast Surg.
Based on clinical experience and the review 2009;62:482–485.
of Villa et al. 11 years ago, the use of thread-lift 6. Rachel JD, Lack EB, Larson B. Incidence of complica-
sutures to perform a closed minimally invasive tions and early recurrence in 29 patients after facial
“face-lift procedure” was considered to be a very rejuvenation with barbed suture lifting. Dermatol Surg.
2010;36:348–354.
promising technique. However, our review clearly 7. de Benito J, Pizzamiglio R, Theodorou D, Arvas L. Facial
demonstrates that, in the past decade, little or rejuvenation and improvement of malar projection using
no evidence has been added to the literature to sutures with absorbable cones: Surgical technique and case
support this statement. All included literature in series. Aesthetic Plast Surg. 2011;35:248–253.
this review except one study demonstrated very 8. Suh DH, Jang HW, Lee SJ, Lee WS, Ryu HJ. Outcomes of
limited durability of the lifting effect. Only two polydioxanone knotless thread lifting for facial rejuvenation.
Dermatol Surg. 2015;41:720–725.
studies, sponsored by the companies that manu- 9. Sulamanidze MA, Fournier PF, Paikidze TG, Sulamanidze
facture the thread-lift sutures (Contour Threads GM. Removal of facial soft tissue ptosis with special threads.
and Silhouette sutures), reported positive results. Dermatol Surg. 2002;28:367–371.
A limited direct lift effect with short longevity is 10. Wu WT. Barbed sutures in facial rejuvenation. Aesthet Surg J.
our main conclusion of this systematic review of 2004;24:582–587.
11. Atiyeh BS, Dibo SA, Costagliola M, Hayek SN. Barbed
the closed thread-lift suture lift in the face. Only
sutures “lunch time” lifting: Evidence-based efficacy. J Cosmet
the use of thread-lift sutures in combination with Dermatol. 2010;9:132–141.
an open procedure seems to be promising. 12. D’Amico RA, Saltz R, Rohrich RJ, et al. Risks and oppor-
tunities for plastic surgeons in a widening cosmetic medi-
Berend van der Lei, M.D., Ph.D. cine market: Future demand, consumer preferences,
University Medical Center Groningen and trends in practitioners’ services. Plast Reconstr Surg.
P.O. Box 30.001
2008;121:1787–1792.
9700 RB Groningen, The Netherlands
13. O’Connell JB. Rhytidectomy utilizing bidirectional self-
b.van.der.lei@umcg.nl
retaining sutures: The bidirectional lift and the extended
bidirectional lift. Aesthet Surg J. 2015;35:633–643.
14. Matarasso A. Introduction to the barbed sutures supple-
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Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.